RY**

1. **Definition.** The art of assisting women in labour. In a more extended sense, it is understood to comprehend also the treatment of the diseases of women and children. In this work we shall consider it in the former limited sense, viz. as relating to the birth of the offspring of man.

2. **History of Midwifery.** It must be very obvious that this art must have been almost coeval with mankind; but in Europe it continued in a very rude state till the 17th century; and even after physic and surgery had become distinct professions, it remained almost totally uncultivated.

It is a curious fact, that in the empire of China the very reverse of this has taken place. In that empire, according to the latest accounts, both physic and surgery are still in a state of utmost degradation, even more so than among the savages of America; but for some hundred years, the art of midwifery has been practised by a set of men destined to the purpose by order of government. These men, who hold in society the same rank which lithotomists did in this country about the beginning of last century, are called in whenever a woman has been above a certain number of hours in labour, and employ a mechanical contrivance for History. for completing the delivery without injury to the infant. A certain number of such individuals is allotted to each district of a certain population.

It is said, that the Chinese government was led to make this provision for alleviating the sufferings of child-bearing women, in consequence of a representation, that annually many women died undelivered, and that in the majority of cases the cause of obstruction might have been removed by very simple mechanical expedients.

Both Sir George Staunton and Mr Barrow were ignorant of this fact; and the latter in particular expressly mentions, that there are no men-midwives in China. But the writer of this article had his information from a more authentic source than the works of gentlemen who were only a few months in that country, and were in a great measure treated as state prisoners. He has it, through the medium of a friend, from a gentleman who resided upwards of twenty years as surgeon to the British factory at Canton, and who had both the ability and the inclination to learn, during the course of so long a residence, all the customs and prejudices of the natives relating to the preservation of human health.

Towards the end of the 17th century, the same causes which had so long before led to the cultivation of midwifery in China produced the same effect in Europe. The dangers to which women are sometimes exposed during labour excited the compassion of the benevolent; so that a considerable part of the first hospital which was established for the reception of the indigent sick, the Hotel Dieu of Paris was appropriated to lying-in women.

The opportunities of practice which that hospital afforded, directed the attention of medical men to the numerous accidents which happen during labour, and to the various diseases which occur after delivery. Public teaching followed, and soon after the custom of employing men in the practice of midwifery began.

From this period the art became rapidly improved; and it is now in many parts of Europe, and particularly in Great Britain, in as great a state of perfection as physic or surgery.

In the year 1725, a professorship of midwifery was established in the university of Edinburgh; and the town council at the same time ordained, that no woman should be allowed to practise midwifery within the liberties of the city, without having previously obtained a certificate from the professor of her being properly qualified. This salutary regulation has fallen into desuetude.

There can be no doubt that the improvement of the art of midwifery was chiefly in consequence of medical men directing their attention to the subject; but the propriety of men being employed in such a profession is much questioned by many individuals of considerable reputeability.

Dr John Gregory, in his Comparative View, p. 22, says, "every other animal brings forth its young without any assistance, but we think a midwife understands it better." Had this eminent philosopher said, "other animals content themselves with the clothing which providence has bestowed, but we think it necessary to cover our bodies with the workmanship of weavers," very few in this northern climate would have attended to the sneer. His son, the present professor, has improved upon the idea. He seems to suppose that women without any instruction, and of course without any knowledge of the subject, are capable of afflicting one another while in labour; and in the sportiveness of his lively imagination, he compares men-midwives to that species of frog, in which, according to the allegation of Reaumur, the male draws out the ova from the female, or, to use the naturalist's words, "accouche la femelle."

It appears to us that this question, on which much declamation has been employed by the parties who have agitated it, may be brought within a very narrow compass. It may be assumed as a fact established beyond the reach of controversy, that sometimes dangers and difficulties occur during labour (from causes to be explained in a subsequent part of this essay), which can be lessened or removed by those only who have an intimate knowledge of the structure of the human body and of the practice of physic. On such occasions, it must be admitted, medical men alone can be useful. But as such labours occur only in proportion of two or three in the hundred, the general practice might be confined to midwives, if they could be taught to manage ordinary cases, and to foresee and distinguish difficulties or dangers, so as to procure in sufficient time additional assistance. It is on this point that the decision of the question must depend. It conflicts with the knowledge of the writer of this article, that women may be taught all this. But there are many who allege, that a little knowledge being a dangerous thing, midwives acquire a self-sufficiency which renders them averse from calling in superior assistance, and that, in consequence, they often occasion the most deplorable accidents both to mother and child. In England this is the popular opinion, so that there women are almost entirely excluded from the practice of midwifery. A similar prejudice against midwives has, it is believed, begun in some parts of Scotland; but it is presumed this will gradually cease, when it is considered that, in general, the Scotch midwives are regularly instructed, and are at the same time both virtuous and industrious. If they attend strictly to their duty, and invariably prefer their patients safety to their own feelings or supposed interest, they will deservedly retain the public confidence. But if in cases of difficulty or danger they trust to their own exertions, or from interested motives decline the assistance of able practitioners, and if they interfere in the treatment of the diseases of women and children, they will in a few years be excluded from practice.

Division of the subject. In order to exhibit an accurate view of what relates to the birth of man, we shall consider, in the first place, conception; secondly, the effects of impregnation; thirdly, the act of childbearing; and lastly, the deviations from the ordinary course which sometimes happen. These topics will form the subjects of the following chapters.

Chap. I. Of Conception.

Three circumstances are required for conception in the human race, viz. puberty; a healthy, vigorous, and natural state of the parts subservient to the operation in both sexes; and successful sexual intercourse.

1. The age of puberty in women differs considerably in different climates. In Europe it takes place commonly between the fourteenth and sixteenth year. This important era is marked by certain changes both in the mind and body. The girl feels sensations to which she had been formerly unaccustomed. She loses a relish for her former amusements, and even for her youthful companions. She seeks solitude, indulges in the depressing passions, and these are excited by the most apparently trifling causes. She feels occasionally certain desires which modestly repel; and it is by degrees only that she regains her former tranquillity.

The changes in her body are even more strongly marked than those in her mind. Her breasts assume that form which adds to the beauty of her person, and renders them fit for nourishing her infant; and every part of the genital system is enlarged. A periodical discharge from the uterus renders the woman perfect.

In young men the same causes produce very different effects. The lad, about fifteen or sixteen, feels a great increase of strength; his features expand, his voice becomes rough, his step firm, his body athletic; and he engages voluntarily in exercises which require an exertion of strength and activity. The changes in his mind are as strongly marked as those in his body. He loses that restless peculiarly which had distinguished his early years, and becomes capable of attending steadily to one object. His behaviour to the fair sex is suddenly altered. He no longer shows that contempt for women, which he had formerly betrayed. He is softened, approaches them with deference, and experiences a degree of pleasure in their company, for which he can scarcely account. In him too there is an important change in the condition of the genital organs.

2. Unless the parts which constitute peculiarity of sex be in a healthy, vigorous, and natural state, conception cannot take place.

In women, conception is prevented if the organs be too much relaxed; if there be obstruction between the external and internal parts; if any premature discharge take place from the internal parts; if the menstrual evacuation be not natural in every respect; and if the appendages of the uterus, called fallopian tubes, and ovaria, be not of the natural structure.

In men, the same circumstance happens if the organs be too much relaxed; if the orifice of the urethra be in an improper situation; if the urethra be diseased; if the testes be not in a natural healthy state; and if there be any defect in the erections penis; which prevents the proper erection of that organ.

3. The sexual intercourse cannot be successful unless somewhat necessary for conception be furnished by both sexes. This consists in the male of a fluid secreted by the testes; and in the female, of the detachment of a substance, supposed to resemble a very minute vesicle situated in the ovarium, and called by physiologists ovum. Each ovarium contains a number of these vesicles. After every conception, certain marks of the detachment of the ovum remain in the respective ovarium.

When the circumstances required for conception concur, a being is produced which generally resembles both parents. This resemblance is most strikingly marked in the human subject, when one of the parents is an European, and the other an African. What is called a mulatto is produced.

The human race possesses the power of propagation in common with all the other species of the animal kingdom, and also, it has been said, with the vegetable kingdom.

As generation then, as it has been styled, is common to two of the kingdoms of nature, it has been imagined by ingenious men, that this wonderful operation is regulated in both by a certain general law. But they have differed much in their account of this law. The question at issue between the two parties is whether the embryos of animals be prepared by the sexual intercourse out of inorganic materials, or whether they pre-exist in the bodies of animals, and are only developed as it were by that intercourse. The former of these opinions is called the doctrine of epigenesis, the latter that of evolution.

Both doctrines have been maintained with much ingenuity by equally respectable authorities. Negative arguments have been adduced in favour of the one, positive in support of the other, and it must be confessed that the balance between them seems nearly equal. The pre-existence of ova in the oviparous animals appears a positive argument in favour of evolution; but the satirical remark of a late witty author, * that, were *Rhumus* this theory true, every individual of the human race *bach* must have been lodged in the ovaria of our first parent, by affording a negative argument in favour of epigenesis, restores the balance.

The various arguments advanced on each side by the opposite parties in this dispute are so very numerous, that we cannot attempt to detail them in this work; and on a subject which has divided the opinions of so many able physiologists, it would be presumption to decide prematurely.

If generation be regarded as an animal operation, one is led to inquire whether the product be the result of the combined influence of both sexes, or whether it be produced by either sex alone.

The first opinion was generally adopted by physiologists, till about the end of the 17th century, when an accidental discovery convinced many that the embryo was produced by the male parent alone; and another discovery some years afterwards again overturned that opinion, and rendered it believed by not a few that the embryo is furnished exclusively by the female parent.

Several circumstances concurred to render the first opinion probable; the structure of the organs which constitute peculiarity of sex in both parents, the circumstances necessary for successful impregnation, and the similitude of children to both parents, appear very strong arguments in its favour.

The second theory, although first brought into vogue about the end of the 17th century by the discoveries of Leeuwenhoek, had been formerly propounded by the followers of Pythagoras. Their argument was analogy: the seed, said they, is sown in the earth, nourished and evolved there; so the male semen is sown in the uterus, and in the same manner nourished and evolved.

Leeuwenhoek's discovery seemed a more conclusive argument in favour of the theory than vague analogy. He observed innumerable animalcula in the seminal fluid of the males of many animals. These he imagined to be embryos.

But as animalcula of apparently the same nature have been observed in many animal fluids besides the semen masculinum, the opinion of Leeuwenhoek and the theory itself are overturned.

It was owing principally to the labours, industry, and ingenuity of Baron Haller, that the third theory, that of the pre-existing germ, became fashionable.

His observations seem to contain a demonstration of the fact.

Those who have adopted this theory, imagine that the semen masculinum possesses the power of stimulating the various parts of the pre-existing embryo. And hence they attribute the filimitude to both parents, and particularly the appearance of the hybrid productions, to that fluid nourishing certain parts, and new-arranging others. But if this were true, then the semen masculinum of all animals should possess the power of stimulating the germs of all female animals; and besides, in each class of animals it should possess certain specific powers of giving a direction to the growth of parts. Experience, however, has not proved this to be the case, for the hybrid productions are very limited; and we may be permitted perhaps, without the imputation of arrogance in pretending to search into the intentions of the Author of nature, to observe, that had the semen masculinum been possessed of such powers, the whole species of animals would have been soon confounded, and the whole animal kingdom would soon have returned to that chaos from which it has been allegorically said it originated.

Yet we are reduced to the alternative of either rejecting the theory, or of believing that the semen does possess the powers alluded to. If we examine attentively the anatomical discovery on which this theory is built, we shall perhaps be inclined to believe that the foundation of the whole is very insufficient; and hence to conclude that the great superstructure is in a very tottering condition. If it be possible that the attachment of the chick to the yolk of the egg should be in consequence of inoculation, the theory must fall to the ground. Haller has endeavoured to obviate this objection, but not with his usual judgment.

Two circumstances, however, seem to show that the attachment is really by inoculation: 1. That vessels are seen in the membrane of the yolk evidently containing blood before the heart of the chick begins to beat; yet these vessels afterwards appear to depend on the vascular system of the chick. And, 2. That in many animals, as in the human subject, the umbilical cord seems to be attached to the abdomen by inoculation; for there is a circle round the root of the cord which resembles a cicatrix, and within a few days after birth, the cord uniformly drops off at that very circle, whatever portion may have been retained after delivery.

There is one objection equally applicable to all the three theories, viz. the difficulty of explaining the steps of the process. A variety of explanations have been offered by ingenious men. Spallanzani and Mr John Hunter lately, Haller and Bonnet formerly, have rendered themselves conspicuous on this subject. Spallanzani, in particular, appears to many to have produced, by his artificial impregnation, the most convincing proofs of the pre-existence of the germ. But to what do his celebrated experiments amount? They show, that in all animals it is necessary that the semen masculinum should be applied to the somewhat expelled by the female during the coitus, otherwise impregnation cannot take place. But was not this universally acknowledged before the abbeé was born? In the unfortunate frogs who were the subjects of his experiments, the whole operation of generation was completed except the application of the male semen to the substances expelled by the female. Nature, by establishing that the substances should be carried on in water, shows that the semen must be diluted, otherwise it cannot fecundate. The abbeé only imitated nature. He left the question in the state in which he found it. His experiment on the bitch may appear more conclusive; but alas! it has never succeeded with any person but himself.

On the whole, since the process of generation is so obscure that no rational explanation of it has yet been offered, are we not entitled to conclude that the general theory which accounts most satisfactorily for the various phenomena which impregnation exhibits is the best; and consequently, that the product of generation cannot pre-exist in the body of either parent exclusively?

**Chap. II. Effects of Impregnation.**

In consequence of impregnation, certain important changes take place in the uterine system of the human subject. We shall consider the natural changes only. On some occasions, there are morbid changes; but we shall not notice them, except in so far as some of them serve to illustrate the nature of the usual ones.

The first visible change is on the ovarium. One of those organs swells out at one point like a small papilla, then bursts, and somewhat is discharged.

A substance is found in the ovarium after this, which is called corpus luteum. Roederer has described very accurately its appearance a few hours after delivery. He says "corpus luteum locatur in rotundo apice. Totam ovarii crassitatem occupat, immediate pone ovarii membranam illa fede tenuiorem locatum; ab ovario cum quo celluloae ope coheret separari sine laetione potest; nulli peculiari ovarii rimae respondet; neque canalis in illo excavatus, sed totum folidum est. Luteus color est, subfinitia acinoa, acinis admodum compactis et ad se preffis ambitus rotundus. Potest aliquo modo, velut in glandulis suprarenalibus, duplex substantia distingui, corticalis et medullaris; quarum illa inaequalis cellulae 1—2 lin. lutea comprehendit hanc medullarem album, quae tenuis et membrana quasi callofa, alium nucleum flavum includit cafforem *." It is very large soon after conception, and then gradually becomes smaller; but never totally disappears. Roederer observes, "post puerperium eo magis contrahi et induari illa corpora videntur, quo remotor fit partes illa qualia videbatur observantur in feminis que nuper partum non ediderunt."

"Lutea corpora quo serius a partu observantur cuncta glandulis suprarenalibus familiae ehe videntur, duplici nempe substantia, exteriore corticali, solida seu flava lutea et nucleo fusco: velut etiam illae glandulae com-+Ibid. pressa sunt +." In cases where there is a plurality of offspring, children, Effects of children, there is evidently a corpus luteum to each impregnated child. In some quadrupeds, as in the bitch or cat, the number of young in the uterus may be generally known by the corresponding corpora lutea in the ovaria.

The next change in the human uterine system which deserves notice is that in the fallopian tubes. They swell out towards the fimbriated extremity, and form a cavity which has been called antrum. Köderer was the first who observed and accurately delineated this change.

He says, p. 14, loco citato, "In hoc etiam utero antrum tubae dextrae appareat, c.f. tab. i. not. 5, ubi quidem in utraque tuba adeunt, in hujus iconis utero ad forum tubam dextram antrum pertinet. Ad uterum feminam oviduum puerperae non longe a fimbria in illiusmodi antrum tuba sinistra prominet: dextra quidem sine antro est, sed versus fimbriam ita flectitur ut ultima flexura dimidium pollicem ultra reliquam tubam effaretur. Tubae feminae qua max a maturo parte mortua est, et alterius tres dies puerperae antris quidem carent, sed multum versus fimbrias dilatantur. An est facta conceptione illa antra nascuntur?"

"In uteri, tab. iv. ovario dextro luteum corpus latet in uteri feminae oviduum puerperae ovario sinistro; in uteri, tab. i. ovario sinistro." He adds, "ulteriores indagines illa antra non indigna esse mihi videntur. Licet forsan conjectare aliquod liquor ex vesicula graeciana in tubam lapillum et ad introitum morans illam dilatam."

But the most astonishing changes are those produced in the uterus itself. Its parietes separate, a cavity is formed which becomes filled with a fluid, and the os uteri is closed up. The matter contained within the cavity soon assumes an organized form. It is said that some time after conception, a small vesicle is observed attached at one point to the internal surface of the uterus; that the rest of the parietes is covered with a gelatinous fluid; and that the whole internal surface assumes a flocculent appearance. By degrees the vesicle, which is in fact the ovum containing the embryo, increases so much in size that it nearly fills the whole cavity in which it is contained, and then its structure becomes the object of our senses.

The increase of size in the uterus is very gradual. It is at first confined almost entirely to the fundus, and it proceeds so slowly that it does not leave the cavity of the pelvis till nearly the fourth month. The principal change in the cervix for the first five months is the complete closure of the orifice, which is effected by a gelatinous fluid: afterwards the cervix is gradually extended, and at last its form is obliterated, the whole uterus becoming like an oval pouch.

After the fifth month the increase of size in the uterus is very rapid. The fundus can be just felt above the pubes about the fifth month, but at the end of the ninth month it extends to the scrobiculus cordis.

Some authors have alleged that the changes in the cervix and in the situation of the fundus are so uniformly regular in every case, that by attending to them it is possible to ascertain the exact period of impregnation. But in this respect they are much mistaken; the changes being not only different in different women, but also in the same woman in different pregnancies.

The texture of the parietes of the uterus seems much altered after impregnation. It becomes spongy and fibrous. The fibres run in very different directions, and from their power and appearance are certainly muscular. The blood-vessels become much enlarged, but are still in a tortuous direction. They are particularly large at one part of the uterus.

The lymphatic vessels, which in the unimpregnated uterus cannot be demonstrated by anastomosis, become, as well as the blood-vessels, remarkably large.

The ovum is not often expelled entire till after the eighth or twelfth week after conception. It is shaped somewhat like an egg, and is about the latter period about four inches in length. When cut into, it is found to consist of four layers or membranes, and to contain a fetus surrounded by a certain quantity of water and connected to one part of the parietes (which is considerably thicker than the rest) by a vascular cord.

The external membrane covers the whole ovum. It is thick, spongy, and very vascular, the vessels evidently deriving their blood from the uterus; it has three perforations which correspond with the openings of the os tineae and fallopian tubes. It has been called decidua, tunica filamento, &c., but its most ordinary appellation is spongy chorion.

The second membrane proceeds from the edges of that part into which the vascular rope which connects the fetus is attached. It was first pointed out to anatomists by Dr William Hunter, and called by him decidua reflexa. The name unfortunately records to posterity the absurd idea respecting its origin which was entertained by Dr Hunter. It is not so thick and spongy as the former membrane, nor so vascular. It lies loyally between the external membrane and that to be next described; but it appears only for a short time, as it soon becomes blended with the others.

The third membrane is thin and transparent, but strong. It is lined with the fourth membrane, and lies in the same situation with it. It contains no vessels at this period of impregnation conveying red blood in the human subject, but in the cow the vessels are very distinct at every period. This membrane however in the early period of impregnation is very vascular, and its vessels are derived from the fetus. The history of a case of morbid impregnation, where the fetus was extra-uterine, detailed by Dr Clarke in the "Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge," proves this circumstance very clearly. He says, p. 220, "a laceration was found to be in the fallopian tube about an inch and a half in length, each extremity of which was about an equal distance from the respective termination of the tube in the fimbriae and in the uterus. The diffusion of the tube at this part was nearly of the size of a large walnut, forming a kind of pouch. More of the coagulated blood being removed from the lacerated part, the flabby vessels of the chorion immediately appeared, interposed with small coagula, and lying in contact with the internal surface of the pouch formed by the fallopian tube; these being separated, and the chorion divided, the amnios showed itself, containing a fetus perfectly formed of above six or seven weeks growth," &c.

This membrane is called the true chorion.

The fourth membrane is even thinner and more transparent... It lines the whole internal surface of the ovum, and together with the chorion is continued along the vascular cord which connects the ovum and fetus. Between this membrane and the chorion, near the insertion of the vascular cord, a small white vesicle appears very distinct at this period; it was first described and delineated by Dr W. Hunter, and was called by him vesicula umbilicalis. At the full period of utero-gestation it is no longer visible, being then quite transparent.

The fetus at this period is between two and three inches in length, and its external conformation is nearly complete.

The fluid contained in the ovum is in such quantity as to prevent the fetus from touching the parietes of the covering in which it is included. It is a clear watery fluid, of greater specific gravity than water, and of a saltish taste. When examined chemically it is found not coagulable by heat or alcohol, and to contain a proportion of ammoniacal and sea salt. This fluid is called liquor amnii.

The connection of the parts thus enumerated with the uterus cannot be explained, unless the appearance of the ovum at the full period of gestation be described.

The ovum then consists of three membranes; a spongy vascular substance called placenta, to which the fetus is connected by a vascular rope, and the liquor amnii.

The three membranes consist of the spongy chorion, the true chorion, and the amnios.

The spongy chorion covers the whole. Its vessels are numerous, and they can be filled by throwing hot wax into the vessels of the uterus.

The true chorion and amnios are in the same situation as in the early months, being continued along the navel-string. They are quite transparent, and contain no visible vessels of any description.

The placenta is a large vascular spongy mass, of various forms in different cases, most generally approaching to a round one, placed on the outside of the true chorion, between it and the spongy chorion. Its external surface is lobulated; its internal or that towards the fetus is smooth, except from the rising of the blood-vessels.

It is not attached to the uterus at any regular place, being sometimes at the cervix or side, but most generally about the fundus. On the one side it receives blood from the mother, and on the other from the child. Mr John Hunter was the first who clearly traced the insertion of the blood-vessels in the uterus into the placenta. He describes it thus (d): "The late indefatigable Dr McKenzie, about the month of May 1754, when assistant to Dr Smellie, having procured the body of a pregnant woman who had died undelivered at the full term, had injected both the veins and arteries with particular success; the veins being filled with yellow, the arteries with red."

Having opened the abdomen, and exposed the uterus, he made an incision into the fore part, quite through its substance, and came to somewhat having the appearance of an irregular mass of injected matter, which afterwards proved to be the placenta. This appearance being new, he flopped, and greatly obliged me by desiring my attendance to examine the parts, in which there appeared something so uncommon.

"I first raised, with great care, part of the uterus from the irregular mass above mentioned; in doing which, I observed regular pieces of wax, passing obliquely between it and the uterus, which broke off, leaving part upon this mass; and when they were attentively examined, towards the uterus, plainly appeared to be a continuation of the veins passing from it to this substance or placenta.

"I likewise perceived other vessels, about the size of a crow quill, passing in the same manner, although not so obliquely: these also broke upon separating the placenta and uterus, leaving a small portion on the surface of the placenta; and, on examination, they were discovered to be continuations of the arteries of the uterus. My next step was to trace these vessels into the substance of what appeared placenta, which I first attempted in a vein; but that soon lost the regularity of a vessel, by terminating at once upon the surface of the placenta, in a very fine spongy substance, the interstices of which were filled with the yellow injected matter. This termination being new, I repeated the same kind of examination on other veins, which always led me to the same terminations, never entering the substance of the placenta in the form of a vessel. I next examined the arteries, and, tracing them in the same manner toward the placenta, found that they made a twist, or close spiral turn upon themselves, and then were lost on its surface. On a more attentive view, I perceived that they terminated in the same way as the veins; for opposite to the mouth of the artery, the spongy substance of the placenta was readily observed, and was intermixed with the red injection.

"Upon cutting into the placenta, I discovered, in many places of its substance, yellow injection; in others red, and in many others these two colours mixed. This substance of the placenta, now filled with injection, had nothing of the vascular appearance, nor that of extravasation, but had a regularity in its form, which shewed it to be a natural cellular structure fitted for a reservoir for blood.

"In some of the vessels leading from the placenta to the uterus, I perceived that the red injection of the arteries (which had been first injected) had passed into them out of the substance of the placenta, mixing itself with the yellow injection. I also observed, that the spongy chorion, called the decidua by Dr Hunter, was very vascular, its vessels coming from, and returning to, the uterus, being filled with the different coloured injections."

It appears then that the placenta has a cellular structure, which receives blood from the arteries of the mother, and that there are veins by which that blood is returned, so that not a drop passes into the fetus. Of this practitioners of midwifery have a very familiar proof. When the placenta is retained attached to the uterus, after the birth of the child, not a drop of blood passes from the umbilical cord, except what was contained in the ramifications of the foetal vessels when the child.

(d) Observations on certain parts of the Animal Oeconomy, by John Hunter, p. 127. child was separated. Yet, if a small portion of the edge of the placenta be detached, such a quantity of blood escapes from the uterine vessels of the mother, as sometimes proves fatal to life: a circumstance which clearly shews that the blood is still conveyed into the cellular part of the placenta.

It has been said, that the placenta on one side receives blood from the fetus. In fact, the greatest part of the placenta seems to be made up of ramifications of the fetal vessels. The internal iliacs of the fetus are conveyed through the vascular rope which connects the placenta and child, into the placenta: they then ramify into as many minute branches as the pulmonary arteries do in the lungs of the adult; they then terminate in various branches, which, uniting, form one large trunk that is conveyed along the vascular rope, and returns all the blood which had been distributed by the arteries.

As Mr Hunter remarks, "the arteries from the fetus pass out to a considerable length, under the name of the umbilical cord; and when they arrive at the placenta, ramify upon its surface, sending into its substance branches which pass through it, and divide into smaller and smaller, till at last they terminate in veins: these uniting, become larger and larger, and end in one which at last terminates in the proper circulation of the fetus. This course of vessels, and the blood's motion in them, is similar to the course of the vessels, and the motion of the blood, in other parts of the body."

The fetus, at the full period, weighs from between 6 and 7, to between 10 and 11 pounds, and measures from 18 to 22 inches. It is placed within the ovum in such a manner as to occupy the least possible space. This position has been beautifully described by Harvey. "Infans in utero utplurimum repertur, adductis ad abdomen genibus, flexis retrosum crucibus, pedibus decupatis, manubioque ad caput sublatis, quorum altem circa tempora vel auriculas, alteram ad genem detinet, ubi maculae albae, tanquam confractionis vestigia, in cute cernuntur: spina in orbem flecitur, caput ad genua incurvato collo propendet. Tali membrorum fitu quemad in hominum per quatem querimus."

The fetus is distinguished from the adult by a great many peculiarities in structure: these the limits of this work do not permit us to enumerate. We shall therefore notice only one peculiarity, which distinguishes the fetus not only from the adult, but even from the natus, viz. the distribution of the blood through its body.

It is well known, that, in the adult and in the natus, all the blood of the body, brought by the two cavae into the anterior auricle of the heart, and from that into the corresponding ventricle, is distributed by the pulmonary artery over the whole substance of the lungs, by means of the most minute ramifications; from whence it is returned by the pulmonary veins into the posterior auricle, and being then sent into the posterior ventricle, is, by its action, transmitted to every part of the body, through the aorta and its ramifications.

But in the fetus the blood follows another course. All the blood of the fetus is returned from the placenta by the umbilical vein, which, penetrating the abdomen, passes between the lobes of the liver, and thence at right angles divides into two branches nearly, by one of which, called ductus venosus, a considerable quantity of blood is carried into the vena cava; by the other the remainder of the blood is sent to the vena portarum; and, after having circulated through the liver, it too is brought by two short venous trunks, the vena cave hepatice, just above the diaphragm, into the vena cava. All the blood thus received into the vena cava, is carried to the anterior auricle; but a part only is transmitted to the corresponding ventricle, for by a particular apparatus, a quantity is at once sent into the posterior or left auricle. Anatomists have differed in opinion concerning the apparatus by which this is accomplished. As there is a small oval hole of communication between the auricles of the fetus, called foramen ovale, having a valve placed in such a manner as to prevent any fluid from passing from the left into the right, but to admit it from the right into the left, it has been generally imagined that the blood passed through that opening. But the simultaneous action of the auricles in the natus seemed to contradict this opinion. A discovery made by Dr Wolfe of Petersburgh appears to solve the riddle. He observed, that in the calf, before birth, the vena cava, at its entry into the heart, divides into two branches, by the one of which it sends blood to the right, and by the other to the left auricle. It is probable that a similar effect is produced in the human fetus by a different structure.

Of the blood sent by the right ventricle into the pulmonary artery, a small quantity only is carried to the lungs; for near the point at which that artery is divided into the two branches that go into the lobes of the lungs, a large branch is sent off, which joining the aorta and pulmonary artery, carries a great proportion of the blood immediately into it. What is circulated through the lungs is conveyed by the pulmonary veins into the left auricle, &c.

All the blood thus received into the aorta is distributed through the several parts of the system, and a large part of it is sent out by the internal iliacs, which, passing out at the abdomen, constitute the umbilical arteries, and distribute the blood in the manner already mentioned over the placenta, from which it is returned by the veins.—The great difference then between the fetus and natus in the circulation of the blood, consists in the quantity distributed through the lungs.

To complete the description of the ovum at the full period of gestation, it only remains that we should say something on the vascular rope, which connects the placenta and fetus, and on the liquor amnii.

This rope is called the funis umbilicalis. It terminates by one end at the placenta, and by the other at the centre of the abdomen of the fetus. Its length and thickness differ materially in different cases. It is longer in the human subject than in any other animal. It is found generally to be from eighteen to twenty-five inches in length, and in thickness about the size of the little finger. Externally it is formed of the chorion and amnios, together with cellular substance. Internally it is found to be composed of three blood-vessels, and a quantity of gelatinous matter. The vessels consist of two arteries and one vein: the vein being as large as both arteries united. These go in a spiral direction, and often form knots by their coils or twiltings. A very small artery and vein are likewise perceived to Effects of go along the cord between the two layers of chorion and amnios, which cover it, into the vesicula umbilicalis. These are called omphalo-mefenteric.

In quadrupeds, a canal, called urachus, is continued from the urinary bladder, along the umbilical cord, and communicates with a membrane, which, like this canal, does not exist in the human subject, called allantois. The urine of the young animal is collected in that membrane.

Some anatomists, as Albinus, have imagined, that the urachus and allantois do exist in the human subject. They were deceived by the appearance of the vesicula umbilicalis and omphalo-mefenteric vessels.

The liquor amnii is never in such proportion to the fetus in the latter, as in the early periods of pregnancy. It is less pure too at that period, being often polluted with the stools of the fetus. Except in this circumstance, its chemical qualities are the same.

We shall now offer a few observations on the changes which have been described.

1. The cause of the increase of growth in the uterus is very obscure. The accession of fluids will account for the phenomenon; but a strong objection occurs against considering that as the cause, i.e., that the uterus increases to a certain degree in size, even although the direction of fluids be to another part, as where the fetus is extra-uterine. Boehmer has marked this very accurately in a case of extra-uterine conception, which he has detailed (A). The development of its fibres seems to prove, that the increase of size depends on a certain energy of the uterus itself; perhaps this may appear a very ambiguous mode of expression, yet we can offer no other explanation of this curious phenomenon.

2. The great bulk of the uterus during the latter months, sufficiently explains the cause of the various complaints which occur at that period. Van Doeveren has described this very accurately. He says, "uteri gravidit incrementum, adficiens e pelvis cavo, et immannis expansio, innumeros excitat gravidarum morbos; primo quidem arctando abdomen et mechanicè compri- mendo viscerà quae in eo continentur, hepatis, lienem, ventriculum, intestina, omentum, nec minus partes illis vicinas, nempe, renes, ureteres, aortam, venam cavam, arterias et venas iliacas, nervoique è medulla spinali pro- deuntes inferiores; secundì pectoris coactio, simileque effectus inde excitati in corde, pulmonibus vasaque majoribus; ex quibus multipliciti modo circulatio, digestio, chylificatio et respiratio laddentur, inque tota corporis economia, ejusque functionibus ingentis, solent produci turbæ variaque vitæ topicæ excitari, inter quæ tensiones, spasmi, dolores, stupores, obturationes, obstructions, inflammations, congelationes præ cæteris memorabiles sunt; unde nascitur magna series morborum abdominis, peitoris, infusque capitis; nec non artuum inferiorum torpores, dolores, crampi, edemata, erythelata, varices, haemorrhagiae, ulcera, labiorum vulvae inflationes, varia- que vitæ partium genitalium, et alia multa pro diversa partium compressarum aut diffentarum actione, variis nominibus insignienda (b)."

3. The origin of the membrane, which appears about the third month, called by Dr Hunter membrana decidua reflexa, has afforded matter of dispute among physiologists. Dr Hunter imagined, that the decidua vera consisted of two layers, and that the ovum, enveloped in chorion and amnios, got somehow between these: but this is a very unsatisfactory opinion. The more probable opinion is, that the decidua vera and decidua reflexa are distinct membranes, although both formed in the same manner. If, as we have already stated, the uterus, soon after conception, be filled with a gelatinous fluid, and if the ovum be in contact with that organ at one point only, then it is probable that the vessels of the internal surface of the uterus, by shooting into the fluid with which it is covered, will form one membrane, the decidua vera; while the vessels on the external surface of the chorion, will thrust into the fluid with which the ovum must have been covered in its descent, and form another membrane, the decidua reflexa.

In proof that both membranes are formed in this way, it may be observed, that where the fetus is extra-uterine, the uterus is lined with the decidua vera, and there is no decidua reflexa.—Boehmer is the first who demonstrated this; and not Dr Hunter, as has been alleged. He says, "Quam vero uterum magnitudine gravi- vido unius circoiter mensis familiariter, eundem po- sterioris longitudinaliter, et superius tranversafilter differ- entium, inque ejus cavo, intuitu haud impregnati satis magno, nihil praeter tenacem et flavescentem mucum, mollemque porofilo-villosam et valvulosam quasi turgescen- tem membranam undique uteri parietes et tubas inven- stentem, hinc inde inflammatam et erofam, structuram autem uteri satis compactam invenimus."

4. The formation of the placenta is a curious subject of inquiry. That it depends principally on the fetus, is proved by the appearances in extra-uterine concep- tions. In the case of ventral conception, published by Mr Turnbull of London, this circumstance is very clearly pointed out (c).

5. The origin of the liquor amnii has been explained very differently by different physiologists. Some imagine that it is furnished by the mother; others by the child. Baron Haller adopts the former opinion. "Ergo (he says) ab utero est, et à matre, siquidem à foetu eft non potest. Non autem experimentum produ- cere, in quo crocus, quem mater sumferat, liquorum amnii tinxit f." But if this were the case, How could the liquor amnii exist when the fetus is extra-uterine? Yet it cannot be a secretion from the fetus itself, be-

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(A) D. Philippi Boehmeri Observationum Anatomicarum variarum fasciculus notabilis circa uterum humanum continens, p. 52.

(b) Prince lineae de cognoscendis mulierum morbis, in usus academicos, ductæ à Gualth. van Doeveren, M. D. et Prof. p. 16.

(c) Vid. A Case of Extra-Uterine Gestation of the ventral kind, by William Turnbull, A. M. F. M. S. Lond. 1791. Plate 1st. Effects of cause it is in very large proportion when the fetus is scarcely visible. From what source then does it proceed? Most probably from the coats of the amnios.

6. Since from the situation of the fetus it has no direct communication with the atmospheric air, two questions occur on the subject; first, whether it be necessary that the fetus should receive the vivifying somewhat which the natus receives from the atmosphere. 2dly, If this be answered in the affirmative, by what means is this somewhat furnished?

1. On looking into the works of Nature, we find that there is a class of animals placed in a similar situation with the fetus, viz. the locomotive fishes. These receive the vivifying somewhat furnished by the atmosphere through the medium of the fluid in which they are immersed; for their blood is always distributed by the smallest ramifications over a substance in constant contact with the water, before it return into the arterial system to serve for the purposes of nutrition.

From analogy therefore it must be allowed, that the fetus does receive, through some means or other, the vivifying principle of the atmosphere.

2. By what means then is this furnished? Many circumstances concur to prove that it is by means of the placenta. For,

1st, The structure of the placenta resembles much that of the lungs. It is cellular, and has the whole blood of the fetus distributed in the smallest branches over its substance.

2dly, The blood returning from the placenta is sent by the nearest possible means to the left side of the heart. And, 3dly, Compression of the umbilical cord to such a degree as to interrupt the circulation through it, destroys the fetus as soon as compression of the trachea does the natus.

It appears therefore that the placenta serves to the fetus the same purpose which lungs do to the natus.

The celebrated Haller has objected to this probable use of the placenta in the following words. "Non pauci etiam auctores fecundis pulmonis officium tribuerunt, cum in vena umbilicali fanguis ruber fit et floridus, si cum sanguinis fodiatis arteriae comparetur. Id experimentum mea non confirmant. In pullo arteria fere coccinea, vena violacea est. In foetu humano nunquam floridum sanguinem vidi; neque intellectu ut placenta, in qua certissime nulla sint acreae mutabiles vesiculae positis pulmonis munere fungi."

But later observations have contradicted the assertions of Haller on this occasion. In particular, Dr Jeffray professor of anatomy in the university of Glasgow, in an inaugural dissertation published here in the year 1786, relates an experiment made by him which is completely opposite to the opinion of Haller. "Puerus," he says, "in oblitricatoris finu jacenti, funiculus tribus vinculis circumjectis, et simul in arctum traditis colligatis est; quo dein juxta umbilicum inciso, in arteriis umbilicalibus et venis, inter duo vincula placenta proxime, sanguinis copia interceptum est. Intercepti spatii vasa, gelatinosa funiculi parte cultro dempta, in conspicuum venerunt; et arteria, quae sanguine jam ante in parte circumlatum, ad placentum perferebat, puncta est; quam prope arteriae punctum vena quoque umbilicalis timider puncta est. Quo facto ex vena sanguis effluens, cum eo qui ex arteria effluat facile comparari poterat. Ille, venosi sanguinis infar, nigricabat; hic, sanguinis in adulta arteriis mox vivide florebat (D)."

7. The means by which the fetus is nourished have hitherto escaped the investigation of physiologists. That the stomach and intestines do not serve this purpose is obvious from many concurrent testimonies; but particularly from these organs being on some occasions entirely wanting, while other parts of the system of the fetus were complete. It is probable that the placenta supplies nourishment, as well as the vivifying principle of the air, to the fetus in utero.

CHAP. III. Natural Parturition.

Human parturition, where every thing is natural, is perhaps one of the most beautiful and interesting operations in nature; for what can be more beautiful than a process accomplished by the combined action of a number of powers admirably well adapted to the intended purpose? and what can be more interesting than the continuation of our species which depends on the operation?

In treating of this subject, we shall first consider the term of gestation; 2dly, the phenomena of natural parturition; and, 3dly, the causes of those phenomena.

SECT. I. Term of Gestation.

The ancients imagined that although nine calendar months be the most usual period of human pregnancy, yet on some occasions that period may be, and actually is, prolonged even beyond ten calendar months. Accordingly, it was laid down as a maxim in ancient jurisprudence, that children born within eleven months after the death of their supposed father should be declared legitimate.

In modern times the question has been often agitated, both among medical practitioners and among lawyers. Practitioners of midwifery however have had most frequent occasion to investigate this subject, and they have differed materially in their conclusions.

Röderer says, "Hunc terminum, finem nempe trigesimae nonae et nonunquum quadragesimae hebdomae dis partui maturo natura, uti accuratior observatio docet confinitut, ultraque cum non facile differtur. Nihil hic valet energia feminis deficiens, morbo vel debilitis patris constitutio, matris dispositio phthisica, hecita, qua fetus sufficienti alimento privatur; nihil status matris cachecticus, fluxus menstruus tempore gestationis contingens, diarhoea aliudve morbus; nihil nimia uteri amplitudine; nihil affectus matris vehementior, qualis trititia; nihil dieta matris extraordinaria, vel inedia; nihil fetus debilitas et dispositio morbo vel plures fetus in utero detenti.

"Tantum enim abest ut haec causa fetus moram in utero retardent, ut potius accelerent. Viduae quidem vanis hisce speciebus, illicitam vencrem defendere atque hereditates aucupari, quin in eo medicos nimis credulos,

(D) Tentamen medicum inaugurale, quaedam de placenta proponens, autore Jacobo Jeffray, &c. Edinburgh 1786, p. 41. But many eminent teachers of midwifery believe that in some cases human pregnancy is protracted for two or three weeks beyond the more common period.

Dr Hamilton especially says, "In the human species nine calendar months seem necessary for the perfection of the fetus; that is, nearly thirty-nine weeks, or two hundred and seventy-three days from conception. The term does not, however, appear to be so arbitrarily established, but that nature may transgress her usual laws; and as many circumstances frequently concur to anticipate delivery, it certainly may in some instances be protracted. Individuals in the same class of quadrupeds, it is well known, vary in their periods of pregnancy. May we not, therefore, from analogy reasonably infer, that women sometimes exceed the more ordinary period? In several tolerably well attested cases, the birth appears to have been protracted several weeks beyond the common term of delivery. If the character of the woman be unexceptionable, a favourable report may be given for the mother, though the child should not be produced till nearly ten calendar months after the absence or sudden death of her husband."

Sect. II. Phenomena of Natural Labour.

The sufferings of a woman during labour having been compared to the fatigues of a person on a journey, the phenomena of labour have been divided into three stages. The first stage consists of the opening of the mouth of the womb; the second, of the actual passage of the child; and the third, of the separation and expulsion of the secondaries.

Phenomena of the First Stage.—In most instances the bulk of the belly subsides for a day or two before labour begins; but the first evidence of the actual commencement of that process is the occurrence of pains in the belly affecting the loins, and striking down the thighs, occasioning considerable irritation of the bladder and bowels. These pains, &c., however, often take place during some hours of the night, for days, or even weeks, before true labour begins, and are then styled spurious pains. It is not easy on many occasions to distinguish true labour throes from spurious pains, unless the state of the mouth of the womb be examined, so very nearly do they resemble each other. But in general spurious pains recur at irregular intervals, and do not increase in force according to their duration; whereas true pains gradually recur at shorter intervals, and become more and more violent.

Spurious pains are sometimes attended with an occurrence which was first publicly noticed and described by the present professor of midwifery in the university of Edinburgh (f), viz., the protrusion of the urinary bladder. This resembles, to a superficial observer, the bag formed by the membranes which inclose the child, and in consequence has repeatedly been burst by the fingers of the operator. Incurable incontinence of urine, inflammation of the passages, &c., have followed this accident.

Protrusion of the urinary bladder may be readily distinguished from that of the membranes which inclose the infant by two circumstances. First, the bag recedes completely during the interval of the pain; and secondly, when pushed down, the finger cannot be passed round it at the fore part of the pelvis; it seems as if fixed to the pubis. True labour-pains arise from the contractions of the womb by which that organ is shortened and thickened; and, at the same time, its contents are forced through its orifice. When they become regular and forcing, they have the effect of opening the mouth of the womb, so that a practitioner can readily ascertain the difference between them and spurious pains. The opening of the mouth of the womb, in most instances, is accompanied by the discharge of a slimy, bloody-like matter, termed flews; but in many women there is no such circumstance.

This process is generally gradual, the pains increasing in frequency and force; and eight, ten, or twelve hours, commonly elapse before they complete the opening of the womb. In some cases the dilatation takes place to a considerable extent before pains occur, so that a few pains accomplish this stage. But these exceptions are not so frequent as those of an opposite description, where one or two complete days are required to open the womb, though the pains be unremitting.

In proportion as the first stage advances, the membranous bag containing the child is pushed through the mouth of the womb, and forced gradually into the vagina. During the pain it is tense, and during the interval it becomes relaxed. When this happens, the head of the infant can be distinctly felt behind it. At last, the passages being sufficiently opened, the pains having become stronger and more frequent, the membranes give way, and the water contained within them is discharged; which finishes the first stage. Shivering, vomiting, headache, thirst, and pain in the back, take place in many instances during this stage.

Phenomena of the Second Stage.—Sometimes an interval of ease of some minutes duration succeeds the discharge of the waters. The pains then become much more violent and forcing, and the head, by the contractions of the uterus thus becoming more powerful, is pushed through the brim of the pelvis into the vagina. For this purpose the vertex is forced foremost, and the brow is turned to one facro-iliac synchondrosis, so that the largest part of the head is applied to the widest part of the bason; for as the head is oval, and the opening through which it is to pass is of the same form, this is absolutely necessary.

After the head is in the vagina, the pains still continuing, the vertex is turned into the arch of the pubis, and the face into the hollow of the sacrum, by which the largest part of the head is brought into the direction of the widest part at the outlet. All the soft parts are now protruded in the form of a tumour, a portion of the vertex is pushed through the orifice of the vagina, and every pain advances the progress of the infant, till at last the head is expelled. An interval of a minute

(f) Roederi Elementa Artis Obstetricae. Goettingae, 1766. page 98. (f) Select Cases in Midwifery, by James Hamilton, M.D. 1795. page 16. When these fibres are evolved, if the uterus be distended farther, the edges of the os tineae must be separated, in consequence of which part of the uterine contents passing through it, the contraction of the uterus follows. A fact very familiar to practitioners of midwifery affords apparently a complete confirmation of this hypothesis, viz., that in some women labour occurs as regularly and naturally, in the seventh or eighth month of gestation, as in others it does at the end of the ninth, the cervix uteri having become quite obliterated.

2d, It is probable, however, that in ordinary cases this store of muscular fibres is seldom entirely exhausted, from the circumstance of women having sometimes twins or triplets; some other cause therefore must concur in exciting the action of the uterus. The contents of the uterus perhaps furnish this cause.

In the latter months of gestation, some parts of the fetus come into contact with the parietes of the uterus, in consequence of the decrease in proportion of the liquor amnii. This is principally the case with respect to the head, which presses on the cervix, and that part of the uterus, it is probable, is more irritable than any other; for we find that the entrance or exit of all hollow muscular organs is more irritable than the other parts, as we see exemplified in the cardia of the stomach, and in the cervix of the urinary bladder.

3d, It is not improbable too, that the pressure of the neighbouring parts contributes somewhat to induce the action of the uterus; for it is remarked by practitioners of midwifery, that women seldom arrive at the full period of gestation in a first pregnancy, and the parietes of the abdomen yield with difficulty at first, as is observed in cases of dropy. Besides all farmers know well, that in every succeeding pregnancy, cows exceed their former period of gestation.

II. The next phenomenon worthy of notice is the manner in which the child's head enters the pelvis. Two circumstances contribute towards this, first the conception of the head of the child with the neck; and secondly, the form of the brim of the pelvis.

The first of these circumstances has been accurately pointed out by Dr Olborn. He says, "after the os uteri has been first opened by the membranes and contained waters, forming a wedge-like bag, the next operation and effect of the labour-pains or contractions of the uterus (for they are convertible terms) must be on the body of the child, which being united to the basis of the cranium at the great foramen and nearer the occiput than forehead, the greater pressure will be applied to the occiput, which being likewise smaller, and making less resistance, will be the first part squeezed into the cavity of the pelvis (e)."

The latter circumstance has been clearly explained by Professor Saxtorph. He remarks, "causa hujus directionis capitis, concurrente toto mechanismo perfecti partus, potissimum haeret in pelvi. Nam agente utero in foetu, in axi pelvis locatum, caput ejus huculque liberum, in humore amni fluctuans, propter molam suam magorem in introitum ipso pelvis magnam resistentiam patitur a prominentia? offis facri, quae in posteriore parte segmenti inferioris uteri ita impellat efi, ut promontorii..." It is remarkable, that neither of these celebrated authors discovered that a combination of both the circumstances just enumerated, is necessary to occasion the phenomenon.

Two advantages result from this position of the head of the child; for, 1st, The largest part of the head is applied to the widest part of the superior aperture; and, 2dly, The head, when the occiput is forced foremost, occupies the least possible space.

III. The phenomenon which next strikes us, is that change in the position of the head by which the face is turned into the hollow of the sacrum.

Although the advantage, and even necessity, of this change in the position of the head, has been long known to practitioners; yet Dr Osborn is, perhaps, the first author who has clearly explained the efficient cause of this. His remarks are these: "As it (viz. the head) descends obliquely through the pelvis, the pressure of the two converging ischia will not be exactly opposite to each other on the two parietal bones; but one ischium acting or pressing on the part of that bone contiguous to the occiput, and the other on the opposite side next to the face, the head being made up of different bones, united by membranes, and forming various sutures and fontanelles, which permit the shape to be changed, and the volume to be lessened, it necessarily follows, that the head, thus compressed, will take a shape nearly resembling the cavity through which it passes; and, as from the convergence of the ischia, the cavity of the pelvis somewhat approaches the form of a cone, the child's head is moulded into that shape, the shape of all others best adapted to open the soft parts, and make its way through the os externum. This unequal pressure of the two ischia upon the head, will, in the first instance, direct the occiput, or apex of the cone, to turn under the arch of the pubes, where there is little or no resistance; while the pressure of the other ischium, in its further descent, will have the same effect on the other side, and direct or compel the face to turn into the hollow of the sacrum."

This change of position is productive of three advantages.

1st, The largest part of the head is again adapted to the widest part of the pelvis.

2dly, The smallest possible surface of the head is applied to the surface of the bones of the pubes. And,

3dly, As Dr Osborn, in the passage quoted, very justly observes, the head is moulded into that shape which is best calculated to pass without doing harm, through the soft parts.

IV. The phenomena which occur when the head passes through the external parts, are easily explained.

After the head has made that turn, by which the face is placed in the hollow of the sacrum, the coccyx and perineum resist its further descent in that direction, and by forcing the nape of the neck against the inferior edge of the symphysis pubis, every successive pain contributes to make the occiput rise up towards the abdomen, by which the chin leaves the top of the thorax, on which it had rested during the preceding process of delivery.

By this simple mechanism, the soft parts are gradually prepared for the passage of the child, while, at the same time, the shoulders are brought into the most favourable position for passing through the pelvis.

V. The phenomena of the third stage of labour obviously originate from the contraction of the uterus, which both separates and expels the secondaries. Some authors have imagined that nature has provided for this purpose a particular apparatus, placed at the fundus uteri; but as the placenta, when attached to the cervix uteri, is thrown off as readily as when it is attached to the fundus, it is very evident that these authors have been deceived by a seeming regularity of fibres, which is sometimes observed.

Lastly, The obstacles which nature has opposed to the passage of the child, occasion all the difficulties of human parturition. These obstacles are formed by the situation and shape of the pelvis, and the structure of the soft parts concerned in parturition.

The pelvis is situated in such a direction, that its axis forms an obtuse angle with that of the body; consequently, it is not placed perpendicularly, but obliquely to the horizon; and hence nothing can pass through it by the force of gravity.

The shape of the pelvis, too, is such, that the head of the child cannot pass through the outlet in the same direction in which it entered the brim; and, from the structure of the soft parts concerned in parturition, they yield with considerable difficulty.

By these means, the Author of our existence has guarded against the effects of the erect posture of the body, and has prevented the premature expulsion of the child and the sudden laceration of the soft parts.

Sect. IV. Treatment of Natural Labour.

First stage.—When this stage proceeds naturally and regularly, there is very little else to be done, after having ascertained that labour has really begun, and that the child is in the ordinary position, than taking care that the bowels be open, and palliating any unpleasant symptoms, such as shivering or vomiting, &c., which may occur.

But if after the pains have become so regular as, by their continuance, to disturb the ordinary functions of life, that is, most commonly, after they have been quite regular for twelve or fifteen hours; if this stage be not completed, it is necessary to interfere, and to endeavour, by art, to effect the dilatation. The reason for this rule is abundantly evident. If this stage of suffering be longer protracted, the strength of the patient must be exhausted by the long-continued exertion, and, of course, the remaining process of labour cannot be completed. Hence the child may be lost, or alarming discharges... Natural discharges of blood may follow the birth of the infant.

This very obvious effect of the protraction, beyond certain limits, of the first stage of labour, was first publicly insisted on by the present professor of midwifery in the university of Edinburgh.

The means to be adopted for completing the dilatation, when that assistance becomes necessary, are veneficent or opiates, or supporting the os uteri, according to circumstances.

When the resistance to the opening of the womb arises from the premature discharge of the water, or from natural rigidity of the womb, copious blood-letting affords the adequate remedy. But if the patient be already reduced by previous disease, so that she cannot safely be bled, an opiate, in the form of glyster, ought to be administered.

And when, on the recurrence of every pain, the mouth of the womb is forced down upon the external passages before the child, its edges ought to be supported, in situ, by the fingers cautiously applied to each side.

Second stage.—When it is found that the head has begun fairly to enter the pelvis in the natural direction, no assistance is necessary till the perineal tumour be formed; and then such support must be given to the protruded parts as shall both relieve the distressing feelings of the patient, and, at the same time, prevent any laceration from happening. Of course, the precise manner of supporting the perineum must be varied according to the circumstances of the case. Inattention to this has very frequently occasioned the most deplorable accidents.

After the head is born, it must be ascertained whether there be any portion of the navel-string round the neck of the infant, and if there be, it must be slackened or drawn over the head, otherwise the infant will be lost.

If possible, time should be allowed for the accommodation of the shoulders, and the expulsion of the body of the infant; and, at any rate, the utmost attention should be paid to supporting the perineum during that part of the process.

Third stage.—When the child is born, and it is ascertained that there is no other infant remaining in the womb, the patient should be allowed to rest for a little, unless pains again come on, by which the secundines are separated. In that case, the cord is to be firmly grasped, and pulled gently, till the placenta be brought down to the external parts, when it is to be drawn out carefully, in such a manner as to bring off at the same time the complete membranous bag.

Should pains not recur at the distance of an hour after the birth of the infant, it becomes necessary, for several reasons, to introduce the hand into the womb to separate and extract the secundines.

First, If the cord were pulled by before the womb had contracted, or the after-birth had become separated, the womb must inevitably be turned inside out; an accident that has occasionally happened.

Secondly, If a longer period than an hour were suffered to elapse, the passages would become so much contracted, that the force required again to dilate them, would produce inflammation, with all its alarming consequences.

Thirdly, If the after-birth were allowed to remain longer than an hour, excessive flooding might take place, which would soon prove fatal.

Fourthly, Were the patient to escape the danger of flooding, she would incur that of putrefaction of the placenta, which is equally, though not so rapidly, productive of mortal event.

In thus introducing the hand to separate the placenta, the two great cautions to be attended to, are to apply the fingers to the substance of the placenta, not to insinuate them between its surface and that of the uterus, and to bring off only that portion of the placenta which can be separated from the uterus without force.

When any alarming circumstance happens after the birth of the infant, requiring the extraction of the placenta, the practitioner is not to delay for an hour, indeed not for a minute, giving the requisite assistance.

CHAP. IV. Of the Deviations from Nature in Human Parturition.

From the view thus given of human parturition, under the most favourable circumstances, it must be obvious that many deviations from nature may occur.

These deviations may proceed; first, from the propelling powers concerned in parturition; secondly, from the state of the secundines; thirdly, from the state of the child itself; or, fourthly, from the state of the passages through which the child is forced. There may also be a combination of these causes. We shall consider each of these causes of deviation in the order just enumerated. But as a minute investigation of the subject would far exceed the necessary limits of this work, we shall treat each of these causes as shortly as possible, and notice only the most striking circumstances.

SECT. I. Of the Deviations from Natural Labour, which proceed from the Propelling Powers.

The propelling powers concerned in parturition consist of voluntary and involuntary muscular action. The diaphragm and abdominal muscles furnish the former, and the uterus the latter.

An excess or diminution of the action of those powers must interrupt the ordinary progress of labour.

a. The violent action of the diaphragm and abdominal muscles, if exerted at the beginning of labour, tends to exhaust the patient and to retard delivery, and if induced when the head is within the vagina, may, provided proper precautions be not taken, lacerate the perineum, and render the future life of the patient miserable.

The action of these muscles being quite voluntary, may be readily prevented by the patient submitting to proper advice.

b. Impaired action of the diaphragm and abdominal muscles, generally originates from the improper exertion of those muscles at the beginning of labour, or from passions of the mind. It always retards delivery, and consequently protracts the sufferings of the patient.

c. Violent c. Violent action of the uterus at the beginning of labour, is frequently productive of much mischief. It exhausts the patient, and renders the subsequent process of delivery exceedingly tedious and difficult. It also sometimes occasions an accident which generally proves almost immediately fatal, viz. rupture of the uterus.

This accident has been described by authors under the title of spontaneous rupture of the uterus. The laceration in the uterus in these cases is sometimes transverse and sometimes longitudinal. When the accident happens from this cause, the laceration is most frequently in the cervix. The accident is preceded by excruciating pain, especially during the action of the uterus, at one part, as in the loins or towards the pubes; and it is announced by a most agonizing increase of the pain succeeded by violent vomiting, the discharge of a little blood, a total cessation of the labour throes, very great irregularity and feebleness of the pulse, cold sweat, coldness of the extremities, difficulty of breathing, inability to lie in the horizontal posture, and sometimes delirium. Along with these symptoms, it often happens that the presenting part of the child recedes entirely, and the limbs of the infant may be readily distinguished through the parietes of the abdomen. But this circumstance does not always take place, for sometimes the head of the child is so firmly wedged within the pelvis, that it does not recede although the other parts be in the cavity of the abdomen.

The rupture of the uterus is generally fatal. A few cases, however, are on record, where, by prudent management, the patient, even under such dangerous circumstances has been saved. Such are the cases recorded by Dr Hamilton (H), by Dr Douglas (I), and Dr Hamilton, junior (K). But the injuries which must ensue from loss of blood, acute pain, the presence of the child in the cavity of the abdomen, and the probable protrusion and strangulation of the intestines are such, that it cannot be expected that many patients can survive the accident.

The cause of violent action of the uterus at the beginning of labour, is obviously the premature discharge of the liquor amnii. By this circumstance, the body of the child comes in contact with the parietes of the uterus, by which the action of that organ is immediately and violently excited. How much mischief then may the rash interference of an ignorant operator produce?

The cause of rupture of the uterus from its own violent action, is the resistance to the passage of the child, either from undilated os uteri, or from deformities of the pelvis, or from wrong position of the child. Whenever, therefore, the rupture is threatened, means must be instantly adopted to remove the resistance, or to suspend the action of the uterus. The former is in general the more easily accomplished.

When the uterus has actually burst, the only chance which can be afforded to the patient, is instant delivery; per vias naturales, where that is practicable; and where there is extreme narrowness of the pelvis, by an incision through the parietes of the abdomen. A case where this latter practice was successfully had recourse to occurred a few years ago in Lancashire.

Violent action of the uterus during the latter stage of labour, although not productive of the same dangers which ensue from it at the beginning, is by no means exempt from hazard; for if the soft parts be rigid or not sufficiently relaxed, the woman may be miserably torn.

The violent action of the uterus towards the termination of labour proceeds from some power of that organ itself, or from the stimulus communicated by the position of the child.

This circumstance, however, is sometimes beneficial; as, for instance, when the child is in an unfavourable position. Dr Denman was the first who discovered this effect of violent uterine action, and published it in the fifth volume of the London Medical Journal, page 64.

d. Impaired action of the uterus during the first stage of labour is in many instances productive of no other inconvenience than the protraction of labour; but if it exhausts the strength of the patient, it influences materially the subsequent process, as already stated. When it occurs during the second stage, it occasions the most dangerous symptoms. First, if the head of the child continue to press for a considerable time on the soft parts within the pelvis, these parts must necessarily from the impeded circulation become swollen, and consequently the action of the uterus, though it should return, would then be totally insufficient for the expulsion of the child. This effect of the protraction of the second stage was first pointed out to the public in Dr Hamilton's letters to Dr Othorn. It merits most particular attention; not only as it is one of the most frequent causes of the loss of the infant during labour, and of considerable danger to the parent, but also as it may be very readily prevented by an attentive practitioner. Previous to this swelling becoming so considerable as to impede the progress of the infant, there is a tenderness and heat, and dryness in the passage, which announces the actual commencement of the inflammation. Immediate delivery ought then to be had recourse to.

Many disagreeable symptoms also proceed from the same cause, such as suppression of urine, and violent cramps in the lower extremities.

When it is ascertained, that, in consequence of the deficiency of action of the uterus, the child is detained so long in the passage as to endanger the health or life of the mother, it becomes necessary to extract the infant by mechanical means. Two contrivances have been thought of for this purpose, viz. the vectis or lever, and the forceps.

Rooskuyten, a Dutch practitioner, who flourished about the beginning of the 18th century, contrived the vectis, and from the great success which attended its use in his hands, an edict was issued by the states-general, that no surgeon should practise midwifery without

(h) Outlines of Midwifery, p. 348. (i) Observations on the rupture of the gravidutenus, &c. by A. Douglas, M. D. &c. 8vo. London 1789. (k) Select Cases of Midwifery, p. 138. out being possessed of the Roohuyzen secret, for the instrument was not publicly known. In the year 1756, however, the secret having been purchased by two liberal-minded physicians, Vlischer and Van de Poll, was published by them for the benefit of mankind. Since that time, the instrument has undergone a variety of alterations in its form; for a particular account of which, the reader is referred to Mulder's Historia Porcipis.

There can be no doubt that Roohuyzen and his successors employed the vectis as a lever of the first species, the head of the infant being the resistance, the parts of the woman the fulcrum, and the hand of the operator forming the moving power. The injuries arising from this practice have been well explained by Dr Ollborn in his Essays on Laborious Labours. Although Dr Bland and Dr Denman still recommend the same practice, there can be no doubt that whenever the use of the vectis proves successful according to their directions, the fortunate termination is to be attributed to the action of the uterus being excited by the pressure of the instrument; or, in other words, the delivery might have been completed without any mechanical interference at all. On the other hand, whenever the action of the uterus is either quite suspended or much weakened, both mother and child suffer from the application of the vectis.

The late Dr Dease in altering the shape of the vectis, wished to impress upon the profession the necessity for changing the mode of employing it; and accordingly he called his instrument an extractor. This power, however, seems to be possessed in a superior degree by Dr Lowder's instrument, of which a description is contained in the eighth volume, second decade, of Dr Duncan's Medical Commentaries, p. 400. As this instrument may be used with perfect safety, both to mother and child, and as in some cases it is superior to the forceps, we have represented its form in one of the plates, and now add the description and an account of the manner of applying it from the work already referred to.

The instrument "consists of a blade and handle (between which there is a hinge, that renders it portable), measuring in length 11½ inches. Its length, before it be curved, is 12½ inches. The curve begins about half an inch from the hinge. It describes, reckoning an inch from its first curvature, as nearly as can be estimated, an arc of 87 degrees of a circle, the radius of which is four inches. The breadth of the blade, at the beginning of the curve, is half an inch, and is gradually increased, till within three quarters of an inch of the extremity, where it measures an inch and three-fourths. Its extremity is semicircular. Within 2½ inches of the extremity there is an oval opening, measuring 2½ inches in length, and 1½ inches at its greatest breadth. By this opening, the depth of the curve is considerably increased, without rendering the instrument inconvenient in its introduction."

Let us suppose that it is found necessary to use Lowder's lever, when the head of the child has just begun to enter the cavity of the pelvis. The patient is to be placed in the ordinary position, on the left side, in bed. The occiput of the child is to be carefully distinguished, and the curve of the instrument is to be applied, with all the necessary precautions, over it. The extremity of the blade should be within a very little of the nape of the neck. To accomplish this part of the operation with facility, it is necessary that the operator be well acquainted with the shape of the pelvis, and that he have accustomed himself to apply the instrument over a round substance.

When the instrument is applied in this manner, the operator will find, that he can exert very considerable power in drawing down, without pressing on any other part than the occiput of the child. The mother cannot possibly feel the instrument; while, at the same time, the many points of the fetal cranium, on which it rests, prevent any injury whatever to the infant.

If there be any pains, however slight they may be, the operator should draw down only during the pain; in the intervals, a soft warm cloth should be wrapped round the handle. If there be no pains, he must draw down from time to time, imitating, as nearly as he can, the natural efforts. It is astonishing, of what use even the most trifling pains are, on such occasions. Without pains, a long time is required before the head be made to advance in a perceptible degree (though, after it has advanced a little, it soon yields entirely); while, with them, the progress is often rapid.

The operator should continue to draw down in the same manner, till the head be completely in the cavity of the pelvis. Should any circumstance, as dangerous uterine haemorrhagy, or convulsions, require that the delivery be expeditiously finished, after the head is brought into this position, the forceps must be applied; for it is in the power of the operator, by means of them, to accomplish the extraction of the head within a very short space of time, or at least, within a much shorter space than would be required, were the use of Lowder's lever continued.

But if there be no dangerous symptom, the operation may be completed by the first instrument, without any assistance from the forceps.

For this purpose, the operator should continue to draw down, by pressing on the occiput, as already directed, until the face shall have turned into the hollow of the sacrum. The direction of the instrument must then be changed. The reason of this is very obvious. After the face is in the hollow of the sacrum, the occiput becomes engaged in the arch of the pubis, and rises under it, while, at the same time, the chin leaves the top of the breast, on which it had rested during the preceding process of labour, and describes a course equal to a full quarter of a circle, which is the consequence of the occiput describing a similar course under the arch of the pubis. Were the practitioner then to continue to press in the same direction as he did while the head was passing through the brim, he would counteract this natural process, and hence would retard delivery, and injure the parts against which he would necessarily press the child.

The instrument must, therefore, be withdrawn from the occiput, and applied with the proper precautions over the chin, when the operator is to imitate the process of nature, by disengaging the chin from the breast, and making the occiput rise under the arch of the pubis, while, with his left hand, he protects the perinaum from injury.

From these observations it is obvious, that the instrument introduced into practice by Dr Lowder, affords exactly the assistance, in the first order of laborious labour, which is required; for it supplies the place of the propelling propelling powers, or increases their efficacy, by acting on the body of the child, without injuring any part of the mother.

"This property renders it of great use in certain cases of deformed pelvis, viz. where the shortest diameter of the brim is about three inches. In such cases, the long continued strong action of the uterus, often eventually forces the head into the pelvis; but the strength of the patient is in consequence so much reduced, that after it has proceeded so far, the pains are entirely suspended, and the delivery must necessarily be finished by the use of mechanical expedients; but the child's life is commonly previously destroyed, by the compression of the brain.

"If, in such cases, it be possible to increase with safety the vis à tergo, the child would then be forced through the brim of the pelvis before the woman's strength were exhausted, and before its life were endangered; consequently, many children, commonly doomed to inevitable destruction, would be preserved.

"Lowder's lever, I apprehend, possesses this power. It may be calculated, that, by its use, the efficacy of the labour throes is at least doubled. Hence the child, in cases of slight deformity of the pelvis, is forced through the opposing part within one half of the time which would be otherwise required; and this is accomplished without injury either to the mother or infant; for the instrument presses on no part of the former; and it rests on such parts of the latter, that no harm can possibly be done.

"In face-cases, too, where the interference of the practitioner is necessary (which, indeed, is a rare occurrence), this instrument may be employed with much advantage. The great aim should be, to draw down the occiput.

"As it appears, therefore, that Lowder's lever is applicable in many cases where the forceps are inadmissible, and that its use is not productive of so much hazard to the mother as that of the forceps, it might perhaps be inferred, that the latter instrument may be banished from practice, as unnecessary and dangerous. Accordingly, many practitioners of midwifery have adopted an opinion of this kind; and, indeed, there are very few who do not employ one or other of these instruments exclusively.

"But however desirable it may be to lessen the number of mechanical expedients, and to simplify practice, I apprehend, that many lives would be lost if we possessed or employed no such instrument as the forceps. As they have the property of a lever, delivery can in many cases be accomplished much more expeditiously by them than by Dr Lowder's instrument. This seems to be the sole advantage which they possess over it; and that is counterbalanced by several great disadvantages. Many authors, indeed, have alleged, that the forceps have exclusively the power of diminishing the size of the foetal cranium, by the pressure of their blades, and hence have attributed a degree of pre-eminence to them, which in fact is not their due; for as the size of the child's head is, in natural cases, diminished as far as is necessary, by the contractions of the uterus forcing it forward through the bones of the pelvis, an increase of the vis à tergo will of course increase that diminution, if the shape of the pelvis require it. While Lowder's lever, therefore, possesses the power of compressing the cranium in common with the forceps, it has a decided superiority over them in this, that it accomplishes that end by similar means with nature.

"The great disadvantages of the forceps are, that they are inapplicable when the child's head is situated high in the pelvis; that their application is often difficult to the operator, and painful to the patient; and that, as their centre of action is on the parts of the patient, they must injure her in proportion to the resistance opposed to the delivery.

"On the whole, then, in cases of the first order of laborious labours, both instruments must be occasionally had recourse to. When the head is not completely within the cavity of the pelvis, Lowder's lever must be employed; and even when it is in that position, the same means may be used, if there be pains. But, when the labour throes are entirely suspended, or when any circumstance renders it necessary to terminate the delivery with expedition, the forceps ought to be employed in preference to every other instrument, if the head of the child be within their reach."

The forceps are supposed to have been invented by Dr Hugh Chamberlain, who was physician to King Charles II.; but their form has been greatly altered since his time. The most approved form is that represented in the plate.

This instrument is only applicable in presentations of the head; but it was formerly, by Dr Smellie and others, recommended in face cases.

In order that this instrument be applicable, it is necessary that the head be completely, or nearly so, in the cavity of the pelvis; but sometimes a lengthened pair is used for cases where the head is situated high. The employment of long forceps, however, being extremely dangerous, is seldom justifiable; and therefore we shall limit our directions to the use of the common short forceps.

There are three principal cases in which that instrument may be had recourse to, viz. 1. where the face is in the hollow of the sacrum; 2. where the face is wedged under the pubis; and, 3. where it is on one side of the pelvis.

In whatever situation the head is, the instrument is to be applied over the ears, otherwise there could be no safe and secure hold. In the process of extracting the child with this instrument too, it is to be observed, that the convex edge of the blades is to be brought along the hollow of the sacrum.

The instrument being applied so cautiously over the ears of the infant that no part of the woman be injured by their introduction, the locking parts are to be brought together, and secured by a ligature; after which the operator, supporting carefully the perineum with one hand, is to draw gently in a direction of from blade to blade during a pain, or now and then to imitate labour throes, while he at the same time favours the mechanism of labour by accommodating the child's head to the passage so as to make it take up the least possible room. If this be done with suitable caution and gentleness, no part of the woman should be injured, and the parts of the infant on which the instrument had rested should not even be marked. But as there can be no doubt, that in the process of using the forceps, the parts of the woman are pressed upon by the blades, if much force be exerted, or if due attention be not paid to the adaptation of the head of the infant to the apertures through which it is to be brought, the most dreadful effects result from the operation.

Sect. II. Of the Deviations from Natural Labour, which proceed from the state of the Secundines.

The membranes which envelope the fetus are in some cases more tender, and in others more rigid, than in general they are found; circumstances which have a considerable effect on the process of parturition. Besides this, the placenta is on some occasions attached to the cervix or os uteri, by which not only is the order of labour interrupted, the placenta being expelled before the child, but also is the patient's life exposed to much danger.

a. Where the membranes are too tender, the liquor amnii is discharged at the beginning of labour before the os tinece be dilated, and then all the bad consequences detailed under the article b, Sect. I, necessarily ensue.

b. Where the membranes are too rigid, the labour may be protracted to such a period as shall injure the mother most materially, and at last, as the whole ovum may be expelled entire, the life of the child may be endangered.

After the os uteri is completely dilated, if the child included in the membranes do not advance into the cavity of the pelvis, the membranes should be ruptured. But if it do, they ought not to be broken till they press on the external parts.

c. But the most alarming deviation from nature, which can proceed from the state of the secundines, is that which originates from the attachment of the placenta over the cervix or os uteri. As there can be no doubt that the uterine vessels dip into the substance of the placenta, and that they are lacerated when the placenta is separated from its attachment, it is obvious that in such a situation hemorrhagy to a most dangerous extent must unavoidably ensue during the process of the labour.

Mr Rigby of Norwich was the first British practitioner who publicly explained this cause of hemorrhagy. In the first edition of his work; viz. that published in 1775, he expresses himself in the following words. "But from the uncertainty with which (as before observed) nature fixes the placenta to the uterus, it may happen to be so situated, that when the full term of pregnancy is arrived, and labour begins, a flooding necessarily accompanies it, and without the intervention of any of the above accidental circumstances; that is, when it is fixed to that part of the womb which always dilates as labour advances, namely, the collum and os uteri, in which case it is very certain that the placenta cannot, as before described, remain secure till the expulsion of the child, but must of necessity be separated from it, in proportion as the uterus opens, and by that means an hemorrhagy must unavoidably be produced.

"That floodings, which arise from these two different causes, which I will distinguish by the names of accidental and unavoidable, though they may appear exactly similar in their first symptoms, should terminate very differently, if left to nature, assisted only by the palliative means before mentioned, cannot seem strange; nor can it be a doubt, that of these two kinds of floodings, only one of them, namely, that which is produced by an accidental separation of the placenta, can be relieved by the use of these palliatives; and that the other, in which the placenta is fixed to the os uteri, and the flooding is therefore unavoidable, cannot possibly be suppressed by any other method whatever than the timely removal of the contents of the womb; for supposing the discharge to be for a while refrained by bleeding, medicine, cool air, &c. it will inevitably return, when nature is so far recovered as again to bring on labour: in the first case, if the hemorrhage have been checked by the use of the above means, it is not impossible but labour may come on, and the child be safely expelled by the natural pains before it returns; or if it should return, it may not increase in quantity; as in this case very probably the separated part of the placenta which occasions the discharge remains nearly the same; whereas in the other case, in which the dilatation of the os uteri produces the separation of the placenta, every return of pain must be a return of the bleeding, and it must become greater and greater as the uterus opens more and more, and the placenta is in proportion detached, till it increases to a degree that exhausts the patient, and she dies before nature has been able to expel the child. That such must inevitably be the progress and event of floodings arising from such a cause, if left to nature, is too obvious further to be insisted on.

"That this attachment of the placenta to the os uteri is much oftener a cause of floodings than authors and practitioners are aware of, I am from experience fully satisfied, and so far am I convinced of its frequent occurrence, that I am ready to believe that most, if not all of those cases which require turning the child are produced by this unfortunate original situation of it (l.)."

No case in practice requires more decision and more attention than this. It must be obvious that no internal remedy can be of any avail in flooding from such a cause, and that the life of the patient can be saved by immediate delivery alone, whenever considerable hemorrhagy takes place. But it is to be recollected that the discharge in many instances threatens for days or even weeks before it becomes serious, and that for the sake of the child, the patient should be allowed to advance as near as her own safety will permit to the full period. These threatenings may often be removed by affringer injections, per vaginam, while at the same time every means of moderating the circulation of the blood should be suggested.

But whenever the discharge becomes profuse, delivery by art is to be had recourse to. The rule of Mr Rigby, and of some other eminent practitioners, "to watch from time to time the dilatability of the os uteri," and take advantage of that state, founds well;

(1.) Essay on the Uterine Hemorrhagy which precedes the delivery of the full-grown Fetus, illustrated by cases by Ed. Rigby, London 1775, p. 14. Vide also 3d edition 1784, same page. but if followed in practice, must either give such a shock to the woman's condition, as shall end in dropy or marasmus, or must prove immediately fatal. In all those cases the os uteri may be forced, and although it be not more open than barely to admit the introduction of the finger, it may in a very few minutes, if the operator have steadiness and perseverance, be rendered capable of allowing the hand to pass.

If possible, the hand should be carried forward at one side of the placenta, for if that part be torn (which it must be admitted is sometimes inevitable) the infant must be destroyed. After the feet are brought down, the child is to be extracted as expeditiously as regard to its safety will permit, and the hand is then to be again passed into the uterus for the purpose not merely of detaching completely the secondaries, but chiefly of securing the contraction of that organ which is the great object of the delivery.

Sect. III. Of the Deviations from Natural Labour, which proceed from the state of the Child.

The regular process of parturition may be interrupted, in consequence of the position and of the shape of the child.

1. Position of the child. The most natural position of the child, at the beginning of labour, is with the head placed at the brim of the pelvis, the face towards the sacro-iliac synchondrosis of one side, and the occiput towards the groin of the opposite side. But there are many deviations from this natural position.

a. Although the head be applied to the brim of the pelvis, it may be forced with the fiscoput towards the promontory of the sacrum, and the occiput towards the symphysis pubis. In this situation the largest diameter of the head is opposed to the smallest of the pelvis, consequently the head remains firmly fixed in that position, for as the fiscoput cannot advance a point beyond the promontory of the sacrum, the occiput is forced just so much below the brim at the pubis as to wedge the head firmly between the sacrum and pubis. By the long-continued pressure the soft parts become much swollen, and at last the head is found so immovably fixed, that it can neither be made to recede, nor can it advance in the same direction. This constitutes what has been styled the caput incuncumatum, or, as it is called by French practitioners, la tête encloquée. This case most commonly is the effect of mismanagement; for if a very little pressure be made on the head when it presents at the brim of the pelvis in this unfavourable position, the pains will readily force it into the passage in the proper direction.

When the locked head has actually taken place, the practice must be varied according to the circumstances of the individual case; hence the long forceps, and sometimes even the crotchet, are required. Turning is quite impossible, and the three-bladed forceps so strenuously recommended by Dr Leake, in this case are totally inapplicable.

b. The long diameter of the head may also be applied to the short diameter at the brim, in a different manner, viz., with the face towards the pubis, and the occiput to the back of the sacrum. The obstructions to the progress of the head are not in this case so great as in the former (a); for as the occiput is round, and its surface inconceivable, while at the same time the promontory of the sacrum is round, the labour throes, after some time, force the occiput either a little to one side, or at least past the promontory. The case, however, is tedious, painful, and even dangerous to the patient; for as the face presents a larger surface to the pubis than the occiput, it must require longer time to pass, and as there are many inequalities on the face, the patient must suffer much pain from their pressure, and from the same circumstance must incur the hazard of having the urinary bladder or the urethra irreparably injured.

In this case Professor Saxtorph remarks, "vel occiput primo defecit, quod cum accidit, frons ab osibus pubis sultentata elevatur, mentiumque pectori infantis imprimitur, urgentibus porro doloribus, verus anus et perineum adagitur acuminatum occiput, et nullo modo sub arcu oculum pubis extorqueri potest inflexible fiscoput, hinc partus in exitu pelvis impotibilis redditur."

That this is a mistake, the observation of other practitioners has sufficiently demonstrated; for it is well known that in such cases, after the perineum has been much stretched the occiput is forced through the parts, and immediately slips back towards the anus, while the nape of the neck being applied to the anterior edge of the perineum, moves on it as on an axis, so that the fiscoput and face emerge from under the symphysis pubis, the chin leaving the top of the thorax in the same manner as if the face were situated naturally in the hollow of the sacrum.

Although in this case the natural efforts most ordinarily complete the process, yet in many instances the injury which threatens the urinary bladder renders the application of the forceps expedient.

c. Although the head may have entered the pelvis in the most natural position, yet it may not make those changes in situation which are required to accommodate it to the outlet; for the face may turn under the symphysis pubis instead of into the hollow of the sacrum. When this happens the phenomena already described take place.

d. It sometimes happens, that instead of the smooth part of the cranium being forced first into the pelvis, the face presents. In this case it may be situated in three positions, viz., with the chin to the sacrum, or pubis, or side.

a.a. The first case is esteemed the most dangerous both for the mother and child. For the mother, because the child in this position requires more room than the pelvis affords, consequently the soft parts in contact with the chin and smooth part of the cranium are much compressed, and hence if the delivery be not speedily accomplished, much injury to those parts will ensue. As the chin too must pass along a curved line formed by the sacrum and coccyx, the obstacles to delivery are very great; and even after the face has been forced so low as to press on the perineum, that part is in much hazard of being torn by the violent dilatation which it undergoes. The delivery in such cases is very rarely accomplished naturally.

This species of labour is equally dangerous to the child as to the mother, not only on account of the long-continued pressure on the brain, but also from the occiput being forced strongly on the superior dorsal vertebra that the free return of the blood from the head is interrupted. interrupted, and hence apoplexy ensues; a circumstance which is proved even by the appearance of children who in such cases are born alive, for the face of such children is perfectly livid. Jacobs has pointed out these dangers pretty accurately. "Il est dangereux pour l'enfant, (he says), parce que la tête étant pendue et portant sur son cou, elle comprime les vaisseaux sanguins au point que le sang ne pouvant plus circuler, il meure d'une apoplexie pour peu que l'on tarde à l'extraction." École pratique des Accouchemens, par le Professeur J. B. Jacobs. A Paris, 1785; p. 366.

b b. The second case, viz. where the chin is placed towards the pubis and the sinciput to the sacrum, is neither so dangerous for the mother nor child. For if by the force of the pains the face be pushed so far forward that the chin becomes engaged within the arch of the pubis, then the inferior edge of the symphysis pubis forms a fulcrum on which the inferior jaw moves, by which the sinciput and occiput pass readily and easily along the hollow of the sacrum, their surface being well adapted to that of the sacrum, and the several parts of the face pass in succession through the vulva.

cc. The third case, viz. where the chin is to one side, is still more favourable than the second; for the face passes readily through the oblique diameter of the pelvis till flopped by the tubercles of the ischia, when the chin turns into the arch of the pubis, and then the same phenomena which occur in the second case take place.

The case most generally afflicting for face-cases is the ill directed exertion of the propelling powers. May it not also depend in many cases on the original position of the foetus?

When any extraordinary difficulty occurs in face-cases, Lowder's lever is the instrument to which recourse ought to be had. The forces, as recommended by Smellie and others, being quite insufficient to afford a safe and secure hold of the infant.

c. On some rare occasions the side of the head presents, so that one ear is in the centre of the pelvis. In such a case, the strongest contractions of the uterus cannot make the head enter the pelvis, and the woman would generally die undelivered were it not for the interference of art. Cases of this kind are remarkably rare.

The hand of the operator must be carried up in such cases, and moderate pressure must be made in such a direction as shall allow the contractions of the uterus to push the smooth part of the cranium into the cavity of the pelvis.

f. The head of the child is not the part always applied to the pelvis; for sometimes the head passes last. Whenever any other part than the head presents, the labour is styled by authors preternatural.

All preternatural labours have been divided into two orders. A. Preternations of the inferior extremities; and B. Preternations of the superior extremities.

A. Preternations of the lower extremities comprehend cases where one or both feet, one or both knees, and the breech present.

g. Cases where both feet present are more frequent than those where one only presents. It has been calculated that the feet present once in 105 cases of preternatural labour.

Some authors have divided labours of this kind into a great variety of species. There is, however, no necessity for such divisions, and they tend to mislead and embarrass practitioners. All the varieties may be reduced under three heads; for the toes must be either towards the side of the pelvis, or towards the sacrum or pubes.

dd. Where the toes are towards the side of the pelvis, the child is generally placed in such a manner that the abdomen, breast, and face pass in succession along the sacro-iliac synchondroses of that side. This is the most favourable situation in which the child under such circumstances can be placed; for the largest parts of its body pass through the largest aperture of the pelvis.

In this case, then, the action of the uterus forcing forward the child, the feet are by degrees excluded through the external parts, the toes being situated between the point of the coccyx and the tuberosity of the ischium; the thighs follow, then the abdomen and thorax; but the farther progress of the child is for some time interrupted by the arms passing up along each side of the head, which add considerably to its bulk; at last, however, the repeated contractions of the uterus force the face into the hollow of the sacrum, and then the nape of the neck turning on the inferior edge of the symphysis pubis as on a pivot, the face is excluded, followed by the sinciput and occiput.

Where the efforts of nature in this process are solely trusted, the child, unless it be small and the pelvis be very capacious, while the soft parts are much relaxed, is generally still-born; for before the obstacles to the delivery of the head be overcome, the long-continued compression of the funis umbilicalis, by intercepting the course of the blood, proves fatal.

ee. Authors have generally considered that to be the most favourable position in which the feet can present, where the toes are towards the sacrum. Roederer for example says, "pedum tunc digiti si offi facro obvertantur, fetus abdomini incumbens recte fitus est (L.)" But two disadvantages attend this position: First, the largest part of the child's body is forced through the smallest part of the outlet of the pelvis; and, secondly, the longest diameter of the head is applied to the shortest diameter of the brim of the pelvis. In such cases, therefore, the patient commonly suffers much pain, and the child's life is destroyed.

ff. When the toes are turned to the pubes, it has been universally acknowledged, that the feet are in the worst possible position. Indeed not only do the disadvantages stated as resulting from the last position (ee) equally take place in this one, but another cause of difficulty and danger is added, viz. that the face being applied to the pubes, the progress of the child must be impeded in no inconsiderable degree. Hence in such a case the patient may be very much injured, and the child must be almost inevitably lost.

The management of footling cases was first explained, in as far as we know, in Dr Hamilton's Select Cases in Midwifery, p. 89.

"It

(L) Roederer Elementa Artis Obstetricae, p. 249. "It is a curious circumstance that the best mode of delivery in fooling cases has not yet been explicitly pointed out by any author. This must appear surprising when it is considered that such presentations frequently occur; that the life of the child depends upon the practice adopted; and that the management of every preternatural labour must be influenced by the rules applicable to fooling cases.

"When the feet present, the infant's situation relatively to the mother must be with its belly placed towards her back, her belly, her side, or some intermediate point. The first of these positions has been generally considered as the most favourable, and the last as the reverse. But a little reflection must convince every practitioner that the infant occupies the least possible space, when its belly is towards the side of the mother, or, to speak more accurately, towards the sacro-iliac synchondroses; for then the largest part of its body is within the largest diameter of the pelvis at the brim, while in its progress through the pelvis, the breech is not forced through the shortest diameter at the outlet, viz. that between the tubercles of the ilium.

"In every case therefore where the feet are brought down, the toes should in the process of extraction be turned into such a position, that the belly, the breast, and the face, shall be made to pass in succession along the nearest sacro-iliac synchondrosis. After the arms are disengaged, the face can be readily turned into the hollow of the sacrum."

h. One foot may present in the same variety of directions as both feet. Where one foot presents naturally, if the pains be regular and strong, the case is attended with less pain to the mother and less danger to the child, than where under similar circumstances both feet present. It is less painful to the mother, because the child is formed into the shape of a cone, and the apex passes first through the pelvis, by which the parts are gradually prepared, and not suddenly forced open; and it is less dangerous for the child, because the one leg being folded along the belly and breast, the umbilical cord is protected from compression.

From these circumstances, a very erroneous inference has been deduced by some celebrated authors, viz. that in cases where it is necessary to perform the operation styled turning, the one foot should be brought down in preference to both. But as on such occasions the operator cannot be assisted by pains, it is obvious that he could not have a sufficient hold of the child by a single foot.

With the exceptions just stated, the phenomena where one foot presents are the same with those which occur in cases where both feet are in the passage.

i. When the knees present, all the inconveniences of fooling cases take place, with this additional danger to the child, that if the legs be crooked, one or both may be fractured before the knees be expelled.

The management of knee presentations must depend on the advance which these parts may have at the time assistance is procured. If they be still at the brim of the pelvis, the feet should be hooked down. But if they be fairly within the cavity of the pelvis, or in the vagina, they must be allowed to protrude without the parts until the feet be expelled.

k. Breech cases occur more frequently than fooling ones. It has been calculated that they happen once in 52 cases of labour.

The breech may present in the same variety of positions as the feet, viz. with the belly of the child to the back, to the belly, or to the side of the mother. Certain advantages and disadvantages attend each of these positions.

When the belly is to the back of the mother, the thigh bones being straight, pass with difficulty along the curved line of the sacrum; after that obstacle is surmounted, the largest part of the child is applied to the smallest diameter at the brim of the pelvis; and after the body is delivered, the head is situated in such a direction that it cannot enter the brim; for the face is opposite to the promontory of sacrum and the occiput to the symphysis pubis.

If the belly of the child be to the belly of the mother, then the thigh bones pass very readily along the bones of the pubes, while the spine bending, accommodates itself admirably to the hollow of the sacrum, consequently at first the labour proceeds speedily and safely; but after the breech has passed through the cavity of the pelvis, it is applied with its largest diameter to the shortest diameter at the outlet, and after it has at last overcome the resistance occasioned by that circumstance, and the body is expelled, the face, being towards the symphysis pubis, subjects the patient to all the pain, and the child to all the dangers, already enumerated (ff).

When the belly of the child is placed towards the side of the mother in breech cases, then the same advantages attend the situation which have been enumerated under the first fooling case (dd); for the largest part of the child is uniformly applied to the largest aperture of the pelvis. Besides this, the child incurs less hazard in this position than where the feet originally present; for the legs being folded on the belly protect the funis umbilicalis from compression.

Breech cases, where the pains are powerful, are to be left entirely to nature, taking care to support the perineum, till the infant be expelled; the navel-string is then to be taken off the stretch, and the child accommodated to the passage on the same principle as fooling cases.

When the pains prove inadequate to the expulsion of the breech, various methods have been recommended, such as hooking the finger in the groin, first on the one side, and then on the other; employing a blunt hook for the same purpose; fixing a garter or piece of tape over one or both thighs, and applying the forceps.

The first of these methods are useful where there are slight pains, and the infant is not large. The second and third methods are injurious both to the mother and child, for they add to the vis a tergo, without diminishing the resistance. But the fourth method, that is, applying the forceps, is invariably both safe and successful; because, while it enables the practitioner to draw forward the child without any uterine action, it at the same time puts it in his power to accommodate it to the passage by turning it round in the proper direction.

B. The second division of preternatural labours, includes all cases where any other part than the head or lower extremities presents; such as the neck, the arm or shoulder, the breast, the back, the belly, or the side. It is obvious, that a full grown child cannot possibly be expelled through the natural passages in such positions, and consequently, unless nature perform the operation first described by Dr Denman, both mother and child must be destroyed; for the unavailing contractions of the uterus will first operate in impeding the circulation of the child; and then by pushing forward its body with great force on the soft parts of the mother, will induce such a degree of pain and inflammation, that she must at last sink exhausted.

The practice of turning, as it is called, that is, of bringing down the feet in cases belonging to this division of preternatural labours, originally suggested by Pierre Franco, but first properly established by Ambrose Parrel, has been the means of saving many valuable lives. Indeed the superiority of this practice to that of making the head present under such circumstances must be very obvious; for after the operator has got hold of the infant's feet, he can complete the delivery without requiring the affluence of pains.

The dangers to be dreaded in performing the operation of turning are rupture of the uterus, or subsequent inflammation of the passages, and loss of the child.

The first of these, is to be guarded against, by pursuing such means as shall suspend the labour-pains, and remove the uterine irritation, when the opportunity of turning before the discharge of the water which surrounds the infant has been lost. These are blood-letting and opiates in large doses, singly or combined, according to circumstances.

Great gentleness and caution, on the part of the operator, are indispensably requisite to prevent both rupture of the uterus and the subsequent inflammation of the passages. When it is added, that a perseverance for several hours is sometimes necessary for accomplishing this operation, it must be obvious, that it demands in many instances a greater degree of patience, as well as dexterity, on the part of the operator, than most cases of surgery.

The safety of the infant, can only be secured, by attending very accurately to the rules for the management of foaling cases.

Dr Denman, whose discovery of the spontaneous evolution has been already mentioned, at one time supposed that in the cases under consideration, the operation of turning might be dispensed with, and that the patient might be saved much hazard, and the practitioner great anxiety and trouble, by waiting for that change.

But although in the later editions of his valuable work (Introduction to Midwifery), he has relinquished this idea, his observations on the management of preternatural labour of the second order, are evidently influenced by his former opinion.

He says (vol. ii. p. 249.), "Yet the knowledge of this fact, however unquestionably proved, does not free us from the necessity and propriety of turning children presenting with the superior extremities, in every case in which that operation can be performed with safety to the mother or give us a better chance of saving the child. Under such circumstances, the instructions given by former writers, and the observations we have before made, must still be considered as proper to guide our conduct. But when we are called to a patient with a preternatural labour, in which there is no room to hope for the preservation of the child, or in which we are assured of its death, or when the operation of turning cannot be performed without violence and some danger to the mother, then the knowledge of this probability of a spontaneous evolution, will let our minds at ease, and disengage us from the consideration of making any hasty attempts to perform a hazardous operation, from which no possible good can be derived, except that of extracting a dead child, and which at all events might be effected by a method much more safe to the mother.

"The time required for the spontaneous evolution of the child, and the facility with which it may be made, will depend upon a variety of circumstances, but chiefly upon the size of the child, the aptitude of its position, the dimensions of the pelvis, and the power exerted by the uterus. If the child be very large or much below the common size, the slower I believe will be the evolution, nor can it be made at all without a strong action of the uterus. It is possible, therefore, when we have conducted ourselves on the ground of expectation that the evolution would be made, that the pains may fall off or be unequal to the effect, and we may be disappointed. It might then be apprehended, that the difficulty of extracting the child would be infinitely increased. But though the evolution was not perfected, I have not found this consequence; for the child, though not expelled, has been brought into such a state that I could afterwards pass my hand with ease, and bring down its feet, though in an attempt to do this at the beginning of the labour I had been foiled. In one case in which the evolution did not take place, I could not bring down the inferior extremities, but I had no difficulty in fixing an instrument upon the curved part of the body of the child, or in bringing it away with entire safety to the mother. It was before presumed that the child was dead, and the sole object was to free the mother from her danger; and with her safety no appearances of the child, however disagreeable, are to be put in competition. In cases of this kind another mode of practice has been recommended, that of separating the head from the body with a blunt hook or other convenient safe instrument; but as I have never practised the method, I give the description of it in a note."

There are two points in the above observations, in which it appears that Dr Denman has erred. In the first place, in sanctioning delay in having recourse to the operation of turning where the superior extremity presents. In many such cases, if the pains be not speedily suspended, or the position of the child altered, the uterus would burst; an accident which has repeatedly fallen under the observation of the writer of this article.

The second error is, the supposition that, after it has been found by experience in any given case, that the spontaneous evolution is not to happen, it is easy to extract the child either by the feet or by force instrument. But it will be found in the majority of such cases, that the infant is impacted into so close a body, while the parts are all in a state of swelling and inflammation, that immense difficulty and great danger attend the attempt.

The following observations on this subject cannot be too strongly impressed on the minds of, especially young practitioners.

"Several "Several years ago, it was discovered by Dr Denman, that in presentations, such as that in the above case, the position of the child is sometimes altered, and its expulsion accomplished, by the natural contractions of the uterus. Although the doctor, with his usual candour, has allowed, that this favourable event, under such alarming circumstances, is rather to be wished than expected; yet he has offered it as his opinion, that if all interference of art were avoided, "the woman would not, in this case, die undelivered."

"The preceding history, however, affords a melancholy contradiction to this opinion. The midwife, who attended from the beginning, did nothing to interrupt the natural process, as far as could be learned. Her fatal error was having only looked on, and having neither given that affluence which was necessary, nor sent for others who could do so.

"The spontaneous evolution, as Dr Denman has called it, can only take place where the child lies in a particular situation, viz. where the action of the uterus cannot be exerted on the presenting part, or where that part is so shaped that it cannot be wedged within the pelvis. A practitioner may, therefore, by a careful examination, be able to decide whether the evolution will happen or not. This observation is by no means a matter of speculation, being, on the contrary, of much practical utility; for, if there be signs which indicate the event alluded to, it follows, as a consequence, not only that the natural process is not to be counteracted, but also, that it is to be assisted. Two cases occurred during one year, where the author of these remarks had an opportunity of prognosticating and assisting the evolution, in presence of two gentlemen then attending the professor of midwifery, as annual pupils.

"That the uterus should continue rigidly contracted on the body of the child, while the strength of the woman was so much exhausted that no pulse could be felt, and that she appeared sinking very fast, is a singular and an instructive fact. It will, it is to be hoped, teach practitioners the fallacy of the assertion, that the longer the operation of turning is delayed, the more easily it will be accomplished.

"It may seem astonishing, that the body of the child could not be drawn down with the crotchet, since it was in a state of great putridity: But when it is considered, that the long-continued action of the uterus had wedged it very strongly within the pelvis, while, at the same time, the pressure on the soft parts lining that cavity had swelled them much, the circumstance will be readily understood."

Authors have endeavoured to ascertain the causes of preternatural labours; but little satisfaction has been derived from their researches. It is probable, that some cases depend on different causes from others. For example, in some women preternatural labour occurs more than once. Such cases seem to depend on some peculiarity in the uterus or ovum. Again, it is well known to practitioners of midwifery, that, on some occasions, where the child had been found to present naturally at the commencement of labour, the position is perceived to be preternatural after the first stage is completed (o). In these cases, the change of position may perhaps be justly attributed to irregularity of action of the uterus. Besides, there can be little doubt that some cases of preternatural labours originate from the premature rupture of the membranes.

2. The bulk of the fetus also occasions considerable deviations from nature in labour; for it may be either too small or too large.

1. The fetus, at the full period of gestation, is never of so small a size as to occasion any deviation from nature, unless it have been for some time dead. It is indeed, a very remarkable fact, that women often carry to the full time a fetus which had died about the fifth or sixth month.

In such cases, the child is sometimes expelled so rapidly, the passages opposing little or no resistance, that the uterus is suddenly emptied of its contents; and hence, from the irregularity of its contraction, the placenta is retained, or uterine haemorrhage takes place.

m. The patient, however, is exposed to more dangers from the increased than the diminished bulk of the fetus. The fetus may exceed the ordinary size, either from a natural increase of bulk, or from monstrosity, or from disease.

k. It has been already stated that the fetus at the full term of gestation, generally weighs from seven to nine pounds; but on some rare occasions it is found to exceed ten or twelve pounds, or even thirteen. Although, however, the process of delivery is not so rapid where the child is so large, yet if no other circumstance occurs to impede labour, it will be eventually terminated with safety both to mother and child in most cases. Where indeed, under such circumstances, the patient has not formerly had a child, there is always reason to apprehend that the infant may be destroyed by apoplexy, or the mother may be very much bruised. In some cases of this kind, it becomes necessary to open the head of the infant.

l. When the child is monstrous, from the redundancy of some large parts, as from two heads or two bodies, it is sufficiently obvious that if the mother be at the full term of gestation, the obstacles to delivery will be insurmountable by the natural powers. Fortunately, however, in by far the greatest number of cases of monsters of that kind, the action of the uterus is excited before the ordinary period.

m. The most frequent disease of children, which proves an obstacle to labour, is the enlargement of the head from hydrocephalus. On some occasions the head is enlarged to an extraordinary size.

Sometimes too, the thorax or abdomen is distended and enlarged by a watery fluid. Professor Saxtorph has recorded the following example of an obstacle to delivery from a very uncommon disease. "D. 18. Sept. 1775. In domo obstetricia regia, mox paritura admitteratur gravida. Infante partus principio dolores partus veri debito modo alternantes, sed solita proportione vehementia, duratione et celiori recurso infligebant. Rite tendebatur."

(n) Select Cases in Midwifery, p. 110. (o) Vide Denman's Introduction, vol. ii. p. 254. tendebatur orificio posteriora versus inclinans; justa erant capitis situs, directio et aquarium formatio; pelvis partetque molliores, viam partus confitentibus, nullo laborant vitio; quibus omnibus accessit adhuc sanus et robustus corporis seminci habitus, et partus aliquoties antea perpessi felix eventus, quae indubie ominabantur incemptum hocce negotium partus feliciter quoque finiendum fore. In progressivo rite procedebat partus.

"In fine vero capite sponte nato, truncus solita facilitate sequi nobebat, quare obstetrix in arte adhuc novitia constitutam domus obstetricem expertem satis faciam libi advocabat.

"Corporis foetus ad latus revoluto, ut humeri in majore diametro aperturae pelvis inferiori minorem facerent resistentiam, brachialisque educitis, junctis viribus truncum ad axim pelvis extrahere mollebantur; attamen obstetabat abdomen nulla illarum vi ulterius cedens.

"In auxilium tune accedent, qui domum isto tempore artem addicendi gratia habitat studiosus, manum sub abdomine prudenter intulit, quod tensum atque complanatum sine omni obituaco inveniebat; ulterius vero manum protrudens pedes tetigit, interque crura tumorem ingentem tenium fluido contento plenum reperiebat.

"Compressa hocce tumore, durum adflantes omni vi truncum timul attrahebant, disruppebatur subito, insigniique aquae copia effluxit; superno sic obstru- lo, facilissime extrahebatur foetus, vitam pro biduum trahens.

"Fortis postea examinatus femellus erat, ingentem saccum inter femora gerens, qui ex elongatione integumentorum universali corporis a tergo versus anteriora ita protractorum, ut orificio ani ex facie anterie corporis prope vulvam conspiceretur, ortum habebat. In ipso facco poft effluxionem humoris, aquae fere lib. iv. capiente, nihil praeter hydatis parvas observatu dignum erat. Os sacro vero, ad angulum rectum verus posteriora curvatum caudae instar prominebat (L.)."

SECT. III. Of the Deviations from Natural Labour, which depend on the State of the Passages through which the Child is forced.

The deviations from natural labour occasioned by the state of the passages, originate either from the soft parts, or the bones.

The obstacles from the soft parts are tumours within the womb, thickening and induration of the neck and mouth of the womb, enlargement of the ovary, cicatrix in the vagina, collection of faeces within the rectum, swelling of the parts lining the pelvis, malformation and extreme rigidity of the external parts.

It is a curious fact, not only that conception sometimes takes place when there is a tumour within the womb, but also that pregnancy goes on to the full period. When this has happened, the tumour has been pushed down before the infant, and has filled up the passages.

If this obstacle be ascertained at an early period of the labour, which it must be if the practitioner be in any ordinary degree skilful and attentive, the tumour may be pushed back, and the feet of the child may be brought down. In a case of this kind, where the writer of this article was called in after the tumour had become wedged within the pelvis, and the head had been opened, the delivery was accomplished with extreme difficulty, and the poor woman survived only a few hours.

The following singular case of an excrescence on the os uteri, is related by Dr Denman, vol. ii. p. 65.

"In June 1772, I was desired to see a patient in the eighth month of her pregnancy, who in the preceding night had a profuse hemorrhage. Her countenance showed the effects of the great loss of blood she had sustained; and from the representation of the case given me by the gentleman who was first called in, I concluded that the placenta was fixed over the os uteri. On examination, I felt a very large fleshy tumour at the extremity of the vagina, representing and nearly equalling in size the placenta, which I judged it to be. Had this been the case, there could not be a doubt of the propriety and necessity of delivering the patient speedily; and with that intention I passed my finger round the tumour, to discover the state of the os uteri. But this I could not find, and on a more accurate examination, I was convinced that this tumour was an excrescence growing from the os uteri, with a very extended and broad basis. I then concluded that the patient was not with child, notwithstanding the distention of the abdomen, but that she laboured under some disease which resembled pregnancy, and that the hemorrhage was the consequence of the disease. A motion which was very evidently perceived when I applied my hand to the abdomen, did not prevail with me to alter this opinion.

"It was of all others a case in which a consultation was desirable, both to decide upon the disease, and the measures which it might be necessary to pursue; and several gentlemen of eminence were called in. That she was actually pregnant, was afterwards proved to the satisfaction of every one; and it was then concluded, that such means should be used as might prevent or lessen the hemorrhage, and that we should wait and see what efforts might be naturally made for accomplishing the delivery.

"No very urgent symptom occurred till the latter end of July, when the hemorrhage returned in a very alarming way, and it was thought necessary that the patient should be delivered. There was not a possibility of extirpating the tumour, and yet it was of such a size, as to prevent the child from being born in any other way than by lessening the head. This was performed; but after many attempts to extract the child, the patient was so exhausted, that it became necessary to leave her to her repose, and very soon after our leaving her, she expired.

"We were permitted to examine the body. There was no appearance of disease in any of the abdominal viscera, or on the external surface of the uterus, which was of its regular form; and when a large oval piece was taken out of the anterior part, the child, which had

(L) Vide Societatis medicae Haumenis Collectanea, vol. ii. p. 23. Pretermature had no marks of putrefaction, was found in a natural potal- tural parturition. An incision was made on each side of the cervix to the vagina, and then a large cauliflower excretion was found growing to the whole anterior part of the os uteri. The placenta adhered with its whole surface; so that the blood which she had lost must have been wholly discharged from the tumour (m).”

In two cases, where a great thickening and induration of the neck and mouth of the womb, approaching to the nature of scirrhosity, had taken place previous to conception, the natural action of the uterus, though after a very considerable time indeed, afflicted by copious blood-letting, eventually overcame the resistance. One of the patients died ten months after, with all the symptoms of real cancer uteri. The other was restored to perfect health after lying in.

Dr Denman has recorded (vol. ii. p. 73.) two cases, where the enlarged ovarium impeded the progress of the child. In the one case the head of the infant was opened, and the delivery completed by the crotchet; but the patient died at the distance of three weeks. In the other, a trocar was passed into the tumour, and a living child was born. The patient recovered from her lying-in; but died hectic at the end of six months. In such cases, the cavity may be pushed back, if the circumstance be discovered early enough.

Cicatrix of the vagina, in consequence of former injury, may appear at first to impede the progress of the infant; but it will always be found to yield to the pains, if the strength of the patient be supported, and proper means be adopted to counteract the effects of the long-continued labour throes. A case occurred some time ago to Dr Hamilton, where a substance, of the hardness of gristle, as thick as an ordinary finger, placed between the vagina and rectum, and apparently extending from the ramus of one ilium to that of the other, presented an insurmountable obstacle to the passage of the child. He was called in after an unsuccessful attempt had been made to tear away the infant, and found the woman in a state of extreme danger. He was informed, that five years before that period, she had had a very severe tedious labour, followed by great inflammation and suppuration of the external parts. The indurated part was cut through without the patient making any complaint, and the child was very easily extracted; but she survived the delivery only two days. The relations would not permit the body to be opened.

A collection of feces within the rectum has been known to occasion such resistance to the passage of the child, that the woman has died undelivered. In general, however, it is in the power of an active practitioner to empty the gut at the beginning of labour. But if, from neglect, the head of the child be jammed in the pelvis, and immovably wedged in consequence of an accumulation of feces, it then becomes necessary to open the head.

Perhaps the most frequent affection of the soft parts which impedes the process of the infant is, swelling of the parts lining the pelvis. This circumstance has been already hinted at. It can never happen where the practitioner is ordinarily attentive; for the tenderness, heat, and dryness of the paillages, which precede the actual swelling, cannot be overlooked by one at all aware of the possibility of such an event. When it has actually happened, nothing can save the mother but opening the head of the infant. After this most unpleasant operation is completed, the extraction of the child is seldom a matter of much difficulty.

Malformation of the external parts in some cases does not prevent conception. Two cases have fallen within the knowledge of the writer of this article, where the woman had conceived though the orifice of the vagina had not been capable of permitting the introduction of even the little finger. And it confits with his knowledge, that about thirty years ago a woman under similar circumstances, was brought into the Royal Infirmary of this place, and was delivered by the Caesarean operation. She died within two days.

It is sufficiently obvious that the safe practice under such circumstances is to enlarge the natural opening, by making an incision in the direction of the perineum, taking care not to wound the sphincter ani.

Extreme rigidity of the external parts is one of the most frequent causes of deviation which depends on the state of the soft parts. It takes place, in a greater or less degree, in the greatest number of women who lie in for the first time; and generally in all women who are considerably advanced in life before they have children.

It is seldom that the resistance opposed by the external parts is to very great as to prove an invincible obstacle to labour. But, on many occasions, the long-continued pressure of the child on those parts produces the most disagreeable consequences, as inflammation of all these parts and of the bladder. Inflammation in these parts is always dangerous, for there seems to be a remarkable tendency to gangrene. Cases are on record where the whole parts have sloughed off, and where the rectum, vagina, and bladder, have formed one canal. Perhaps death is much preferable to life under such circumstances.

Copious blood-letting, and the liberal use of some unctuous application, with time and patience, in general overcome the rigidity of the external parts. Placing the patient over the steams of hot water was formerly recommended in such cases, but this practice is now exploded.

B. Many deviations from natural labour occur from the state of the bones of the pelvis, for they may be so much altered in shape as either to increase or diminish considerably the aperture of that part.

d. When the apertures of the pelvis are too large, the mother incurs much danger, and the child is not totally exempt from hazard.

aa. The danger incurred by the mother arises from there being no resistance to the passage of the child, so that when the action of the uterus begins, the child may be pushed by the force of the pains through the paillage before the soft parts be dilated; hence the uterus may be ruptured, or the soft parts lacerated. If,

(m) Were such a case again to occur, there could be no doubt respecting the propriety of fixing a ligature round the neck of the tumour. on the other hand, the external parts be soft and yielding, a considerable portion of the uterus may be excluded without the parts. There is a very wonderful history of a case of this kind alluded to by Saxtorph in the following words. "Memorabilius adhuc exemplum est illud à cel. Wolffg. Mullnera allatum, ubi totus uterus una cum foetu extra genitalia dilapius, festuque vivus extra pelvim verifone extractus fuit, matre post reductionem uteri superflite. Vide ejus Bahrnehmung von einer samt dem Rinde aufgefallenen Debahrmutter, Nurnberg 1771 (l)."

bb. The hazard which the child undergoes is that of being suddenly expelled, included within the entire ovum, so that it may be lost before proper assistance can be afforded. Another danger is, that the membranes having given way, it may be dashed with violence upon the floor on which the patient walks. Whenever from the great width of the hips, there is reason to suspect that the pelvis is too large, the practitioner should continue in constant attendance from the very commencement of labour, and should carefully adopt the appropriate and obvious means to prevent the hazards just enumerated.

c. But deficiency of space in the apertures of the pelvis occurs much more frequently than increase. The apertures of the pelvis may be diminished from natural small size or malformation of the bones, from exostosis, or from altered shape in consequence of mollities of osium.

Cases where the sacrum and ilia are of an uncommon small shape are not frequent. Narrowness of the base of the sacrum is sometimes met with; and in a few cases it has been found that the apex of the sacrum has approached too nearly to the anterior part of the pelvis, so as to diminish the apertures at the outlet.

Exostoses seldom prove an obstacle to delivery; but one exception to this rule fell under the observation of the writer of this article several years ago. The exostosis extended along the whole extent of the symphyses pubis, and was fully as thick as an ordinary sized finger. The woman had been delivered previous to his being called in, but the exhaustion which followed, (for she had been allowed to continue five days and nights in constant hard labour) occasioned her sinking a very short time after delivery. In this instance both mother and child were lost from the self-sufficiency and ignorance of the midwife.

The deficiency may exist in the brim, the outlet, or the cavity singly or combined.

The brim is much more frequently affected by mollities of osium than the outlet; and, as was long ago remarked by Levret, it generally happens, that when the brim is narrowed from this cause, the outlet is widened.

The brim may be diminished in size by the projection of the promontory of the sacrum, or by the flattening of the pubes, or by the approximation of the bones where the pubes and ilia unite, or by a combination of some of these circumstances. The projection of the promontory of the sacrum, however, is by far the most common. When this happens, the projection sometimes renders one side of the pelvis wider than the other, and this constitutes what authors call the distorted pelvis. Sometimes, however, it leaves both sides of an equal width, and this is called the deformed pelvis.

The deficiency in the brim produced by these causes is very various; most frequently slight, but sometimes so great that there is not an inch between pubes and facrum.

The outlet may be diminished by the approximation of the tubercles and rami of the ischia, or by the apex of the facrum and coccyx projecting more than usually forward, while they are at the same time hooked up.

When both the brim and outlet are diminished in aperture, the cavity of the pelvis is generally affected also; but when the deficiency of space is confined to either, the cavity is commonly more shallow than natural, by which both the resistance and the danger are considerably lessened. Melancholy are the cases where the cavity is rendered deeper than usual.

As the practice in cases of extreme deficiency in the apertures of the pelvis is to be regulated by the degree of narrowness, it is a matter of the first importance to be able to ascertain the dimensions in any given case with tolerable precision.

For this purpose, instruments called pelvimetres have been invented. M. Coutouli has proposed one for internal use, and M. Baudelocque has recommended one for external application. But however plausible in theory the use of such contrivances may appear, it is now well known that no dependence can be placed upon them in actual practice, and therefore the hand of the operator must be had recourse to for determining both the shape and the extent of the apertures of the pelvis, wherever there is any narrowness. The following directions for this purpose given by Dr Wallace Johnstone are extremely judicious.

"On passing the finger along the vagina, if the coccyx, or any part of the facrum, be felt unfluently forwards or near at hand; or if the symphyses, or any other part of the pubes, is found projecting rather inwards than outwards, it is evident that the pelvis is distorted. In which case, as well as in those where it is not distorted, but only very small, the principal part of the child's head (allowing the presentation right) remains high, the vertex making only a little round tumor within the brim: so that when the os uteri is opened, and come a little forwards towards the pubes, the capacity of the pelvis may be found out by moving the end of the finger round that part of the head which has entered the upper strait. This method is used by several practitioners in London. However, should the finger not be long enough to effect it properly, as sometimes is the case, there is then another method, which, being more certain, may be used, provided it be done with tenderness and caution, and when the orifices are so well opened as to admit of it with safety. But previous to it, the operator must be well acquainted with the dimensions of his own hand, viz.

"First,

(l.) Dissertatio Inauguralis de Diverso Partu, &c. Auctore Matth. Saxtorph. p. 46. Firstly, The fingers of a middle-sized hand (as we may suppose the operator's to be) being gathered together equally into the palm, and the thumb extended and applied closely along the second or middle joint of the finger; the distance between the end of the thumb, and outer edge of the middle joint of the little finger, is usually four inches.

Secondly, Whilst they are in the above position, the distance from the thumb, at the root of the nail, in a straight line to the outside of the middle joint of the little finger, is full three inches and a half.

Thirdly, The fingers being still in the same situation, and the thumb laid obliquely along the joints next the nails of the first two fingers, and bent down upon them; the distance between the outside of the middle joint of the fore finger, and the outside of that of the little finger is three inches and a quarter.

Fourthly, The hand being opened, and the tops of the four fingers being a little bent, so as to come nearly in a straight line; their whole breadth, across the joint next the nails, is two inches and a half.

Fifthly, When the first three fingers are thus bent, their breadth across the same joint is two inches.

Sixthly, The breadth of the first two, across the nail of the first finger, is one inch and a quarter.

And, seventhly, The fingers being gathered into a conical form, the thumb lying obliquely upon the palm of the hand with its point upon the first joint of the ring finger, reckoning downwards, will measure in thickness, between its back and the fore part of the thumb, two inches and two-eighths.

Now, as hands are extremely various, the operator ought always to know how much the size of his differs from the above dimensions; and this being rightly understood, the application may be made as follows:

The patient, being in the position as for natural delivery, and the operator's left hand being well anointed, and the fingers and thumb gathered into a cone, it must be gently passed into the vagina, and then through the os uteri, unless in this part there is still a rigidity to forbid it; if so, the fingers only must be passed, their extremities formed into the fourth dimension, and then placed edgways in the strait; which being done, if the fore finger touch the angle of the sacrum, and the little one the symphysis of the pubes, the width is then manifestly no more than two inches and a half; a space through which a mature child can neither pass alive, nor be brought so by art, unless it happens to be preternaturally small indeed."

Three methods of practice have been adopted in cases of such narrowness of the pelvis as renders it impossible for the child to be protruded alive, viz. the operation of embryulcia or embryotomy, the Caesarean section, and the division of the symphysis pubis.

I. Embryotomy. The cases requiring this most shocking operation are those where the infant cannot be extracted alive through the natural passages; while there is, nevertheless, such space that it may be torn away piece-meal without injury to the mother. Of Preternatural Parturition, in these cases the life of the woman can be saved only at the expense of her infant.

But although authors and practitioners in modern times adopt in general this principle, they differ materially in their account of the precise cases requiring the operation.

Dr Osborn alleges, that, as the head of the infant at the full time of utero-gestation cannot be diminished to less than three inches between the parietal protuberances by the natural contractions of the uterus forcing it against the bones of the pelvis; wherever the aperture at the brim or outlet falls under three inches, the operator ought to proceed as soon as possible to open the head of the infant.

But on so very serious an operation as that by which one life is destroyed, it becomes a practitioner to adopt no rule which can be at all liable to error; and it is evident, that there are three very strong objections to this precept of Dr Osborn.

Firstly, It is impossible in any case at the beginning of labour, to ascertain that the infant is at the full term of utero-gestation; but it is well known, that a child at the age of between seven and eight months, if born alive, may be reared to maturity, and that such a child is capable of being expelled without injury, through an aperture incapable of permitting the passage of a full grown fetus.

Secondly, The heads of children, even at the full time, are sometimes so small and so yielding as to admit readily of their short diameter being diminished below three inches.

Thirdly, Every candid practitioner must allow, that it is quite impossible to ascertain with geometrical accuracy the precise dimensions of the pelvis; and consequently what in any given case may appear to the operator to be less than three inches, may in fact be above these dimensions.

For these reasons, wherever the narrowness is not obviously very considerable, the prudent rule is to ascertain the effect of the labour-throes, supporting the strength of the patient, and palliating distressing symptoms. By adopting this rule, the practitioner will not only have the consolation of not having destroyed life unnecessarily, where he is eventually forced to open the head, by the conviction that it is too large to pass unopened, but also the innate satisfaction of sometimes saving a life, which under less cautious management must have been sacrificed. Great care indeed is necessary in such cases not to be deceived in the estimate of the progress of the child, for the swelling of the scalp may mislead a young practitioner.

There has been a variety of opinion too, respecting the lowest dimensions of the pelvis which permit the operation of embryulcia with safety to the mother; and it is surely unnecessary to state, that unless there be a moral probability of saving the life of the mother by this operation, it ought never to be had recourse to.

Dr Kellie, of London (P), and Dr Osborn (Q), have recorded some cases where this operation was performed, although... Although the narrowness was very great; and the latter gentleman, founding on a single case, affirms the principle, that whenever there is a space equal to an inch and a half between pubes and lacrum, the operation of embryotomia is practicable. But a careful perusal of the case alluded to (A) must satisfy any unprejudiced person that there must have been some mistake, most probably, from the swelling of the soft parts lining the pelvis having added to the apparent narrowness, and having, after the head had been opened above 36 hours, subsided. And at any rate, since experience has now fully established the fact, that the danger resulting from this operation is always in proportion to the degree of resistance, it may be concluded that the operation of embryotomia cannot prove safe to the mother, unless, first, there be an aperture equal to about two inches by four; and, secondly, the narrowness be chiefly, if not altogether, confined either to the brim or the outlet. When both brim and outlet are deficient, and the cavity is deeper than usual, even although the several apertures be quite sufficient to allow the diminished head to be extracted, the injury that must accrue from the violent pressure on all the parts within the pelvis would deter any prudent practitioner from hazarding such an operation.

When it is determined to have recourse to the operation of embryotomy, the instruments required are the perforator, the crotchet, and the embryotomy forceps delineated in the plate.

The operation is to consist of two different processes; first, the diminution of the head; and, secondly, the extraction of the mangled child. In many cases the latter should be performed immediately after the former is accomplished; but whenever the resistance is very considerable, an interval should be interposed between the two. The advantages resulting from this practice were first publicly noticed by Dr Osborn, though there can be little doubt that the practice itself was the effect of necessity. By waiting after the head has been opened, the woman's strength will be restored, so that the assistance of the pains in the expulsion of the child may be obtained; the swelling of the soft parts will subside, by which the resistance may be greatly lessened, as well as the danger of inflammation removed, and the child's body will become putrid, by which its extraction may be greatly facilitated.

In opening the head, which is to be done by means of the perforator, the two great points to be aimed at are to avoid injuring any part of the woman, and to make a sufficiently large opening of the head. On the complete accomplishment of the latter, the eventual success of the operation must depend in all cases of extreme deficiency of space.

Should it be found expedient to delay the extraction of the infant after the head has been opened and its contents evacuated, the teguments are to be carefully brought over the ragged edges of the bones, so that in the event of labour throes recurring, there shall be no risk of the parts within the pelvis being injured.

When it has been found proper to proceed to the extraction of the infant, the first thing to be attempted is to diminish the bulk of the cranium as much as possible. This may be done by means of the embryotomia forceps, delineated in the plates, and contrived it is believed by Dr Lyon of Liverpool. It is an instrument far superior to the almudach of the Arabians, in use even within these fifty years among the practitioners of this island (B).

After the head has been sufficiently reduced in bulk, the crotchet is to be fixed at first on the inside of the cranium; and while two fingers of the left hand are to be kept constantly so applied that if the instrument should slip in the process of extraction, it shall be received on the fingers, and cannot possibly touch any part of the mother, the operator is to draw down with a suitable exertion of force, in such a direction that the largest part of the head shall be brought through the widest part of the pelvis.

In some cases, much time and very violent exertions are required to accomplish the delivery; but, if the proper precautions to prevent any injury to the panniculus be adopted, and if at the same time the operator imitate nature by working only from time to time, and increase the force employed gradually as may be required, and persevere patiently, notwithstanding the resistance, taking care to support by nourishment and cordials the strength of the woman, the delivery at last will be completed.

The dangers to be dreaded from this most shocking operation, are injuries of the panniculus, from the instrument's slipping through the embarrassment of the practitioner; or violent inflammation of all the contents of the pelvis extending to the abdomen, in consequence of the parts through which the child must be so forcibly extracted being severely bruised. Accordingly, a greater number of women die from the effects of this operation than practitioners are willing to admit; and indeed, in every case of extreme deficiency of space, where embryotomy is performed, the recovery is to be regarded as doubtful.

This operation is sometimes had recourse to in cases where the forceps should have been used had the child been alive. But such cases are very rare, because the evidence of the infant in utero being dead, is seldom so complete as to justify the practitioner proceeding on the principle that it is so.

II. By the Cæsarean section is meant the extraction of the infant through the parietes of the abdomen by an incision into the uterus.

This bold operation was perhaps never performed by the ancients on the living subject, and certainly was first recommended to practitioners by M. Roussel in his Traité nouvelle de l'Hystérotomie, &c. 1581. Since that time it has been often performed on the continent, and about twenty times in Great Britain. The success of this operation recorded in the early works has certainly been exaggerated; but it appears by an elaborate memoir by M. Baudelocque, translated into English by

(A) Osborn's Essay, p. 240. (B) For an account of the ancient instruments employed in the practice of midwifery, see Sculteti Arment. Chir. by Dr Hull of Manchester, that during the 50 years preceding 1802, the operation has been had recourse to on the continent 95 times, and that 37 of these cases proved successful. In Great Britain, on the contrary, this operation has never yet succeeded, a circumstance to be attributed partly to the delay which has always taken place after the necessity for such an expedient had been determined, and hence the patient, at the time the operation was performed, must have been in a state of exhaustion; and partly, perhaps chiefly, to the previous very alarming state of health of the subjects of the operation in this island. It is at any rate certain that all over the continent practitioners have less horror at performing the Caesarean section than British practitioners have commonly shown; and it is deemed necessary in cases where the operation of embryotomy is preferred in this country, and where of course the women are not in such a precarious state of health as those commonly are who have extreme narrowness of the pelvis.

In consequence of the fatality of the Caesarean section in Great Britain, several eminent practitioners have regarded it as unjustifiable. Dr Osborn has rendered himself particularly conspicuous on this subject, and uses very strong language in reprobation of it. His arguments are, its acknowledged fatality; the capability of completing the delivery by means of the crotchet, in cases of such deformity of the pelvis, that there is no more than one and a half inch between the pubis and sacrum, or to one side of the projecting sacrum; and the impossibility of impregnation taking place in cases of greater deficiency of space. We shall notice these arguments in their turn.

1stly, The acknowledged fatality of the operation.—This relates only to the result of the operation in Great Britain; for, as already mentioned, a great proportion of the patients has been saved on the continent. But in inflicting on this argument Dr Osborn has overlooked that the object of the operation is to save, if possible, two lives, and at any rate one. Now if it can be satisfactorily proved, that on some occasions the operation of embryotomy is absolutely impracticable, it becomes the duty of the practitioner to save one life at least; and it is well known that the Caesarean operation is far less painful to the woman than that of embryotomy, even where that latter operation is eventually successful. In such cases of extreme deformity, either an attempt should be made to deliver the woman and save the child, or both must be allowed to perish; for the operation of embryotomy, if attempted, must be regarded as wilful murder.

2ndly, The practicability of tearing away the child in pieces by means of the perforation and crotchet, in cases where there is no more than an inch and a half between the pubis and sacrum, or to one side of the projecting sacrum, is alleged by the doctor on the foundation of a single case, that of Elizabeth Sherwood already referred to. But any person who shall take the trouble to have the aperture of Sherwood's pelvis, as stated by Dr Osborn cut out in wood, and to compare this with the basis of an infant's skull as much diminished as possible by the crotchet (which is done in the course of his lectures by the professor of midwifery in this university), must be convinced, that there was no mistake in the supposed dimensions of that woman's pelvis. And it is quite obvious, that unless there be the space already stated, viz. three and a half or four inches by two, it is unsafe to extract the mangled child through the natural passages.

3rdly, The allegation that where there is a greater degree of narrowness of the pelvis than that which was supposed to have happened in the case of Sherwood, impregnation cannot take place, is quite inconsistent with facts. One of the most remarkable cases of extreme deformity is that of Elizabeth Thompson, on whom the Caesarean operation was performed at Manchester in 1802. The description as given by Dr Hull (g) is as follows: "The pelvis of this patient was not nearly so soft as has sometimes been observed. It still had a considerable degree of bony firmness. The os innominata at their sacro-iliac symphondroses, and at the symphysis pubis, before the pelvis was dried, admitted of a slight degree of motion.—The distance from the crista of one os ilium to the other, at their most remote points, measures ten inches and a half.

"The alae of both osa ilia are very much bent; and on the left side the curvature is so great, that it measures only two inches from the anterior and inferior spinous process to the opposite posterior point. The lumbar vertebrae project forwards or inwards, and make a considerable curve to the left side of the pelvis. The distance from the lower part of the second lumbar vertebra to the anterior part of the spine of the os ilium, on the left side, is two inches. The distance from the lowest part of the second lumbar vertebra to the anterior part of the spine of the os ilium, on the right side, is five inches.

"Superior aperture. The conjugate or antero-posterior diameter, from the symphysis pubis to the upper edge of the last lumbar vertebra is one inch and a half. This diameter is not taken from the os sacrum, or its junction with the last lumbar vertebra, because the point of their junction is so much sunk into the pelvis, that the place it should have occupied, is represented by the junction of the fourth and fifth lumbar vertebra. The transverse diameter measures four inches and five-eighths. It is taken from one sacro-iliac symphysis to the other. The distance of the point of this aperture, which is opposite to the anterior part of the right acetabulum, from the lumbar vertebra, is only half an inch. The distance from that part of this aperture, which corresponds with the posterior part of the right acetabulum, to the os sacrum is three-fourths of an inch. The distance of the point, corresponding with the anterior part of the left acetabulum, from the lumbar vertebra is five-eighths of an inch. The distance of the point of this aperture, opposite to the posterior part of the left acetabulum, from the os sacrum, is three-fourths of an inch. The distance of one os pubis from the other, in the points marked in the plate, is seven-eighths of an inch. The distance from the right sacro-iliac symphysis to the symphysis pubis is three inches and three-fourths. The distance

(g) Observations on Mr Simmons's Detection, &c. p. 195. distance from the right sacro-iliac symphysis to the left os pubis is three inches and three-eighths. The distance from the left sacro-iliac symphysis to the symphysis pubis is three inches and five-eighths. The distance from the left sacro-iliac symphysis to the right os pubis is three inches and one-fourth. The largest circle, that can be formed in any part of the superior aperture, does not exceed in diameter one inch.

"Inferior aperture. The distance from one ramus ossis ilicthi to the other, where they are united with the rami ossium pubis, measures only half an inch. The distance from the tuberosity of one os ilicthium to the other measures one inch and two-tenths. The conjugate or antero-posterior diameter, taken from the symphysis pubis to the point of the os coccygis is three inches.

"The angle, included by the rami of the os pubis, is very acute, viz. an angle of about 20 degrees. The perpendicular height from the tubera of the os ilicthia to the inferior margin of the symphysis pubis is two inches and a half. The perpendicular height of the symphysis pubis is one inch and a half. The tuberosity of the left os ilicthium advances forwards, beyond that of the right, about six-tenths of an inch, and the whole of the rami ossis pubis and ilicthii on the left side projects beyond those of the right. The perpendicular height of the os sacrum and coccyx is two inches and one-fourth only, the os sacrum being bent so as to form a very acute angle. The acetabula, at their nearest points, are only three inches distant. The symphysis pubis is much more prominent than natural. The upper margin of the symphysis pubis is situated as high as the bottom of the fourth lumbar vertebra."

It appears then, that Dr Osborn's arguments are fallacious, and that cases occur where the operation of embryotomy is neither safe nor practicable. Under such circumstances, the Caesarean section must be had recourse to; and it is therefore to be regarded as an operation of necessity, not one of choice. If this rule be adopted, the cases requiring so formidable an expedient will happily be very seldom met with.

Mr Simmons of Manchester, observing that Dr Osborn's third argument is untenable, has proposed in the following words, another substitute for the Caesarean operation.

"When a case shall arise in which the child cannot be delivered by the crotchet, from the brim of the pelvis being no more than one inch in diameter; I propose to combine the two operations, and to divide the symphysis pubis to make way for the crotchet. Dr Osborn has urged several objections against this proposal, although he admits that the operation at the symphysis is not so certainly fatal as the Caesarean section. Weighty objections doubtless press against it; but whilst there are no other means for preserving life, bad as the chance is, it becomes a question whether it be worth risking; and, after maturely considering the case, should an attempt for saving the life of the mother be judged expedient, as the last resource it may be adopted.

"The space gained has been differently stated at from three to eight or nine lines in the diameter;—the medium distance would probably be sufficient to accomplish the delivery by the crotchet.

"The objections urged against this mode of delivery, when the head is of the full size, will not apply to its reduced bulk; and it should be remembered, that the symphysis is formed of cartilage and ligament; so that whatever pressure shall be made against the divided edges, will not be made against the sharp angles of bone. That much injury may be done anteriorly will not be denied; but does the continued pressure of the child's head never produce mischief in other cases? By the introduction of a female sound for a guide, a cautious and steady operator will avoid wounding the urethra; and, as the base of the skull will probably be turned sideways, it will suffer less in extraction than in other cases of the crotchet; in which it must in general be injured from pressure against the pubis. If the separation, however, be carried beyond a certain length, laceration will probably ensue; and, should this accident occur, I see no reason to apprehend more danger from it than follows the extraction of a large stone from the bladder through a small opening, which will induce a lacerated wound, but which we know will not uncommonly heal. The sacro-iliac ligaments would certainly not be injured by choice, but the consequences, I believe, are not generally fatal; and, should it be urged that great pain and lameness will afflict the patient for a long time after, a reply will readily occur, that life was at stake; and surely there are few who would not compound, for the prospect of temporary pain and inconvenience, to have it preferred to them.

"A spontaneous separation sometimes occurs, both there and at the pubis; and yet the patient has been again restored to health.

"I do not see, in other respects, in what this compound operation differs from the most difficult crotchet case—the Caesarean section is certainly fatal to the mother in this country—the life of the child, it is agreed, shall not be put in competition with the parent's life—the section of the symphysis is neither to formidable nor so fatal as the Caesarean section—and the crotchet has been successfully applied in dimensions which will probably be thus acquired.

"Upon the whole, then, in that supposed case of distortion (which I hope will never happen) in which the mother must be doomed to death, from the impossibility of delivering the child by the crotchet, the compound operation I have recommended will furnish a resource, approved by reason and sanctioned by experience; inasmuch as the section of the symphysis pubis has been made, and the crotchet has been used, though separately, yet with safety. Such a case will be attended, unquestionably, with additional hazard; but it offers the only chance to the mother, to the preservation of whose life our chief care should be directed: and I hope that in future all trace of the Caesarean operation will be banished from professional books; for it can never be justified during the parent's life, and stands recorded only to disgrace the art."

He himself has afforded the most satisfactory evidence of the absurdity of his own proposal; for he had not published it many months when the very case he had described as ideal actually occurred in his neighbourhood, and he had the opportunity of making the experiment of his own plan. But he shrank from it, and no wonder; for the woman was Elizabeth Thompson, whose pelvis has just been described. It is unfortunate that Mr Simmons has not had the candour to confess his error, and to retract his opinions, more especially since his reflections With respect to the mode of performing the Caesarean section, there has been considerable variety of opinion. On theoretical principles, the external incision, viz., that through the parietes abdominis, ought to be in the direction of the linea alba, because there is less chance of any considerable retraction of muscular fibres, or of interfering with the intestines, than if it were made in any other direction. But the result of the practice seems at variance with the theory. According to the testimony of Baudelocque, of 35 operations, where the incision was made on the side of the abdomen, eighteen proved successful; of thirty in the direction of the linea alba, ten only succeeded; and of eight in the manner recommended by Lauverjat, that is, by a transverse incision between the recti muscles and spina dorsi, three succeeded. But it may be remarked, that the event, in many of those cases, may have been influenced by a variety of circumstances, totally independent of the line of direction of the external incision.

In whatever part of the abdomen the external incision be made, it ought to be extended to fix inches; and, previous to cutting into the uterus, any active arterial branch, which may have been divided, must be secured; and the liquor amnii, if not already discharged, must be drawn off. The opening into the uterus need not be above five inches in length, and should be made as much towards the fundus as possible. Means are to be employed to prevent the protrusion of the intestines at the time the uterus is emptied. Both foetus and succedanea are to be quickly extracted; after which, the hand is to be palmed into the uterus, to clear out any coagula which may have formed within its cavity, to prevent the os tineae being plugged up, and, at the same time, to promote the contraction of the uterus. The wound in the uterus is to be left to nature; but that of the parietes of the abdomen is to be carefully closed by means of the interrupted suture and adhesive straps; and the whole belly is to be properly supported by a suitable bandage or waistcoat. In the after treatment of the patient, the great objects to be held in view, are to support the strength and moderate the degree of local inflammation.

III. Division of the symphyis pubis.—This was originally proposed and performed by M. Sigault of Paris. His proposal was made in 1768; but he had no opportunity of making the actual experiment till September 1777.—The succeds of his first case was such, that a medal was struck to commemorate the event; and the operation was admired and recommended, with all the extravagance of French enthusiasm.

The operation consists of the division of the symphyis pubis and separation of the innominata. For this purpose, a catheter is to be introduced into the urethra, and, with a common scalpel, the articulation is to be cut through from the upper edge of the symphyis, to within a quarter of an inch of the inferior edge. By separating the thighs, the divided bones are forced asunder. After this, the operator is either to turn the child, or to extract it by the forceps, according to the circumstances of the case.

This expedient was proposed as a substitute, both for the operation of embryotomia, and for the Caesarean section, as it was alleged to be perfectly consistent with the safety both of mother and child.

It is quite unnecessary for us to offer any theoretical objections to this operation, because we can now reason on the event of thirty-five cases, which have been published.—But those who may wish to investigate this subject, may consult Baudelocque, par 1994 and 2091, inclusive; and Dr. Osborn, p. 271. To that latter practitioner's professional zeal and ability is chiefly to be ascribed the total rejection of this operation in Great Britain.

Of the thirty-five subjects of the published cases (for in one woman it was performed twice), fourteen women and eighteen children died.—Of the twenty-one women who survived, nine had either had living children before the Sigaultian operation, or had such at a subsequent period. Most of the remainder suffered much from the operation. Some had incurable incontinence of urine, others lameness, &c. But the most important fact is, that whenever the bones of the pelvis were separated from each other above an inch (and no space of any consequence could be added to the brim, unless they were so), the sacro-iliac synchondroses were torn, and no woman survived that accident.

These facts have at last convinced foreign practitioners of the futility of this expedient; and, accordingly, for above ten years, it has not been performed on the continent by any practitioners of respectableability.

When a woman, with a narrow pelvis, who has had the good fortune to recover after the operation of embryotomy, again falls with child, she should not incur the hazard of a repetition of so horrible an operation; but ought to have premature labour induced between the seventh and the eighth month. Under the direction of an intelligent practitioner this operation is easily performed; and, while it affords the only chance of saving the infant, which it is the duty of the mother and of the practitioner to attempt, it at the same time, by lessening the resistance, diminishes both the suffering and the risk of the patient (x).

For a further account of the practice in cases of extreme deformity of the pelvis, the reader is referred to Osborn's Essays; Hamiltons Letters to Osborn; Simmons's Reflections, and Hull's Detection of Simmons.

SECT. IV. Of the Deviations from Natural Labour which happen from anomalous circumstances.

Certain circumstances besides those already enumerated occasion deviations in the process of labour. Some of these respect the child, and others the woman.

a. The child's life is endangered if the navel-string be so strongly convoluted round its neck, that after the head is born the remainder cannot be expelled without the cord being drawn so tight as to interrupt the circulation through it. Dr Denman, vol. ii. p. 16, has stated this as a cause of protracted labour, and has advised.

(n) See a paper on this subject; in the 18th volume of the Medical Facts and Observations, by Mr Barlow.

Pretermi- nated certain modes of practice in consequence. But if there be pains, there cannot be any material protraction of the labour from this cause.

All risk of the infant may be prevented by slackening the cord, and waiting for the action of the uterus, if the operator find that he cannot draw the loop of cord which surrounds the child's neck easily over its head. But this in most cases can be readily done.

b. The cord is sometimes pulled down before the presenting part of the child.

If this happen before the membranes are burst, the only certain method of saving the child is to perform the operation of turning as soon as the state of the passages will permit.

When the cord is pulled down along with some other part, as the head, after the waters are discharged, a variety of practice is required according to the circumstances of the particular case; hence merely keeping the cord for a little time beyond the presenting part by means of the fingers, or wrapping it up in a piece of soft rag, and pushing it above the presenting point, or the application of the forceps, are generally found useful in different cases.

c. Sometimes one or both arms of the child are forced down along with the head, where proper assistance is not had at the beginning of labour. If the pelvis be roomy, and the woman have formerly had children, the delivery may be at last completed by the natural powers, notwithstanding this increased degree of resistance. But in many cases of this kind an experienced practitioner is not called in till the strength of the woman be very much exhausted, and then it becomes necessary to use the forceps, or even on some occasions to have recourse to the operation of embryotomy.

d. It is well known, that sometimes there is more than one child in the womb. Instances where there are twins are not unfrequent; cases of triplets are alleged to happen once in between three or four thousand births; four at a birth have not occurred in this city for the last twenty-seven years; and there are only two, or at most three, well-authenticated cases of five at a birth having happened within a hundred years in this island.

All the signs by which the existence of more than one child in utero can be ascertained, previous to the actual commencement of labour, are fallacious; and in general it is not till after the birth of one child that it can be determined that another remains in the womb; and, unless under very particular circumstances, it is of no importance. The circumstances alluded to are where different parts of both children are forced into the passage at the same time. Of this a very remarkable case is recorded in the book of Genesis, verse 27, chap. xxxviii.

When the womb appears to remain bulky and hard after the birth of one child, there is reason to suppose that it contains a second. But if there be any doubt on the subject, the practitioner has it in his power to ascertain the point by examination. When there is no second child in the uterus, the further the fingers are carried up within the passages, the more contracted do they feel; whereas, if there be a second child, the more open are they found.

When it is ascertained that another infant remains, the woman's belly should be immediately compressed by means of a roller, in order to prevent faintness from the sudden relaxation of the parietes abdominis, and the portion of the navel-string remaining attached to the after-birth of the first born should be carefully secured, lest the vessels of the placenta anasto-

mose.

In regard to the subsequent treatment, there has been much variety of opinion among practitioners. Some have proposed waiting till the action of the uterus expel the second as it had done the first infant. Others urge strongly the necessity for immediate delivery.

Against the former of these practices it is to be objected; firstly, that in some cases, days or even weeks have been known to intervene between the birth of one child and the action of the uterus which expelled the second. Secondly, that if this happen, the passages must become contracted and their subsequent dilatation may be productive of inflammatory symptoms. Thirdly, that during the time the uterine action is suspended, internal haemorrhage may take place, and may destroy the patient. And, fourthly, the second child may be suddenly forced down in such a position, as may endanger its life, and at the same time occasion great pain to the mother.

For these reasons it is now an established rule among judicious practitioners, to examine the situation of the second infant, as soon as the patient shall have recovered from the shock of the birth of the first child; and, if its position be natural and the patient have not been exhausted by the previous labour, and pains come on, to rupture the membranes, and allow the natural powers to complete the delivery. But if the infant present any other part than the head, or though the head do present, if the woman be exhausted, or if there be no appearance of the return of pains within an hour after the birth of the first, then the hand is to be passed up to bring down the feet of the second child, and the delivery is to be expedited. The extraction of the placenta is to be conducted with great care, and every possible precaution is to be adopted against the occurrence of flooding, which is always to be dreaded as the consequence of plurality of children.

The same principles apply to the management of triplets, &c.

d. Umbilical hernia, to which women are perhaps more subject than to any other species of rupture, may influence the labour materially.

If it be reducible, it disappears after the fifth month of pregnancy; but immediately after the expulsion of the child it returns, and occasions frightful faintings and floodings. This may be prevented by the simple expedient of having the belly compressed by a roller in such a manner, that in proportion as the infant advances, the compression may be increased.

Should it be irreducible, if the hernia be affected by the continuance of labour, as may be known by the colour, &c. the operation of turning must be had recourse to.

e. Convulsions sometimes happen during labour, and occasion great danger both to the mother and the child. The woman is quite insensible during the fit, which consists of violent convulsions of the muscles which move the body, and of those of the eyes, the face, and the lower jaw; it lasts in some cases only a few seconds, and Opening the external jugular might answer both purposes, but the difficulties of the patient in many cases makes the surgeon or attendants dread this operation. A quantity of blood, therefore, adapted to the exigency of the case, is to be drawn from the arm, and either a branch of the temporal artery is to be divided, or several leeches are to be applied to the temples. After the bleeding, a powerful laxative glyther ought to be exhibited. And if there be any evidence of disordered prime vae, an emetic must, if possible, be given. The state of the os uteri is then to be ascertained; and if labour have not commenced, no attempts whatever are to be made to promote that process. In some rare cases, however, where the bulk of the gravid uterus is enormous, it may be necessary to remove a part of its contents; but such cases cannot happen once in a thousand instances of the disease.

Should the fits still continue, the head must be shaved, and covered with a large blister; and if the oppression or fulness, or hardness of the pulse, be not removed, the blood-letting is to be repeated.

As soon as the patient becomes capable of swallowing, the camphor, in doses of ten grains, ought to be given every three or four hours. The most efficacious and palatable form in which this medicine can be prescribed, is by suspending it in boiling water, through the medium of alcohol, sugar and magnesia. Its use must be persevered in for several days, gradually lessening the number of doses.

Where the eclampsia has been preceded by oedema, the digitalis may be employed with much success.

Convulsions during labour are to be treated upon the same principles, with these additional precautions, that delivery is to be accomplished by the most expeditious possible means, and that if the delivery be followed by uterine haemorrhage, the discharge is for some time to be rather encouraged than checked. I knew two instances of the fits, which had been suspended for some hours, recurring, in consequence of the flooding being stopped, and in both cases the convulsions were removed, by allowing the discharge to return.

When the symptoms that precede eclampsia, take place in the latter months of pregnancy, the most certain method of guarding against the threatening accident is, having recourse to immediate blood-letting, and afterwards prescribing camphor, attention to the state of the bowels, and a spare diet.

When the same symptoms occur during labour, a copious bleeding should be instantly ordered, and the appropriate means of terminating the delivery should be adopted with as much expedition as may be consistent with the safety both of mother and child.

In these concise practical suggestions, practitioners will observe circumstances omitted, which have been recommended by gentlemen of deserved professional eminence, and novelties of practice proposed, which I believe have not hitherto been explicitly advised. Some explanation, therefore, of the plan above recommended may perhaps be expected.

The most obvious remedy apparently omitted is opium. This powerful medicine was not prescribed, as far as we have reason to know, by the practitioners who lived at the end of the 17th and beginning of the 18th centuries. The first author who, in strong terms, affirms the efficacy of opium in such cases, appears to be the translator. translator of Astruc's Midwifery (A); and his opinion has been adopted by Dr Denman (B), and by Dr Bland (C). But in every case of true eclampsia, during pregnancy or labour, opiates do irreparable mischief, where a copious bleeding has not been prevented; and even where that precaution has been attended to, they have been found useless, if not hurtful. Melancholy experience has completely established in my mind this practical precept; and I consider it to be a matter of very great moment, that it should be universally known; for general practitioners, who are often first called to those cases where the fits happen during pregnancy, are extremely apt to prescribe opium. I can solemnly declare, that no patient to whose assistance I have been called, who had taken a dose of opium previous to my arrival, has recovered, and I have known that medicine given in almost every variety of dose. My father, Dr A. Hamilton, of whose judgment and practical knowledge it does not become me to speak in the terms they so justly merit, prevented my ever employing opium under such circumstances.

"A second remedy extolled by Dr Denman, and now, after a fair trial, rejected in my practice, is vomiting. This seems to have been a very common prescription in the time of Mauriceau, as he takes great pains to point out its hurtfulness in several parts of his works (D). Where there are unequivocal marks of disordered stomach, an emetic may be prescribed with advantage after blood-letting, but it should be avoided under all other circumstances.

"With regard to the warm-bath, which is a favorite remedy among foreign practitioners, and has been advised by several British authors, I have never had an opportunity of trying its effects. Upon theoretical principles I should reject it; but my chief reason for never having directed its use, has been the imposibility, in ordinary cases of practice, of commanding a warm-bath into which a woman in such a situation could be put.

"Dashing cold water by surprise upon the face is a practice suggested by Dr Denman, and on which he had much dependence at one period. Experience lessened his hopes, and, many years ago, prevented my ever indulging any. I gave it several fair trials, (once or twice in public in the lying-in ward of the Royal Infirmary), and had even reason to be convinced, that it rather aggravated than diminished the violence of the paroxysms."

In addition to these observations it may be proper to remark, that a much larger quantity of blood should be drawn in those cases than has commonly been done. Dr H. advises forty ounces to be taken at this first bleeding, and the same quantity to be again drawn within an hour, if the symptoms be not mitigated; and he talks with the utmost confidence of the utility of this practice.

f. Although the woman be delivered safely both of the child and afterbirth, she may sink very soon after parturition in consequence of internal flooding. This is to be suspected if the patient suddenly complain of giddiness or sickness, or ringing in the ears, or impaired vision; or if she become delirious, with a pallid face and cold limbs. The state of the pulse at the wrist too should lead a judicious practitioner to suspect the existence of internal flooding. Positive certainty of this accident may be obtained by feeling through the belly the condition of the uterus; or, more certainly still, by feeling the state of the vagina, for if its parietes approach, there is not much probability of there being any considerable internal hemorrhage; whereas, if it be found filled with coagulated blood, there is a certainty, that the womb too is distended from the same cause.

This accident is entirely owing to the womb not having contracted with sufficient energy. It very often proves the cause of sudden and unexpected death.

The boldest and apparently most violent measures are required to save the patient in many of those cases. The womb and vagina must be immediately emptied, and such pressure must be made on the inside of the uterus with the hand, as shall force it into contraction. In some cases cold water in great quantity must be dashed from a height on the naked belly at the same time; and in the mean while the strength of the patient must be supported with large doses of opium. If there be vomiting, which is a frequent symptom in such cases, five grains of solid opium should be given at first, and afterwards three grains every three or four hours, till the pulse becomes steady and the strength recruited, when the opiates are to be withdrawn and lessened by degrees. The writer of this article cannot avoid this opportunity of paying a just tribute of respect to the practical discernment of the able editor of the New London Medical Dictionary, who seems the first author who has mentioned this practice of giving large doses of opium; a practice by which many valuable lives have been saved.

Conclusion.—In the preceding account of the deviations, which sometimes happen in the process of human parturition, although we have endeavoured to give a full view of the subject, we have not pursued the beaten track. But as this article may rather be consulted by many as a dictionary, than pursued regularly as a treatise, we shall add the ordinary arrangement of labours, with the reference to the numerical articles, under which the several varieties may be found.

Labours are divided into four classes; viz. natural, laborious, preternatural, and complex.

Natural labour comprehends all cases where the head of the infant is forced foremost; and the whole process is completed with safety, both to mother and child, within twenty-four hours from the commencement. It is described under articles 48. to 60.

(A) The Art of Midwifery, &c. 8vo. London, printed for J. Nourse 1767. Appendix, p. 295. (B) Vol. ii. p. 418. (C) Loco citato, page 136. (D) Particularly in Aphorism 232. "L'émeticque est pernicieux aux femmes grosses, ou nouvellement accouchées, qui sont surprisées des convulsions." And Levret, page 451. of his L'Art des Accouchemens, says, in reference to that aphorism, "Cette sentence est des mieux fondées, et elle doit être rigoureusement observée dans tous ses points." Laborious labour is that where, although the head of the infant be forced foremost, the process is protracted beyond twenty-four hours from the commencement. It is divided into three orders: First, where the natural powers at last, after much suffering on the part of the mother, complete the delivery. See article 64.

Secondly, Where, although the action of the uterus be inadequate to the expulsion of the infant, it is practicable to extract the child through the natural passages, without injury either to it or to the mother. See articles 66. to 74. 82 and 84.

Thirdly, Where it is impossible to extract the child alive through the natural passages. See articles 80. and 99. to 133.

Preternatural labours comprehend all cases where any other part of the child than the head is forced foremost; and consist of two orders:

First, Presentations of the lower extremities, viz. footling cases, article 87. Breech cases, article 91. Cases where one foot presents, article 89. and knee-cases, article 95.

Secondly, Presentations of the superior extremities or other parts than the head or lower extremities, articles 192. to 196.

Complex labours include all cases where any other circumstances than those enumerated under the former three classes take place, viz.

Cases where the pelvis is too large, articles 110. and 111.

Cases where haemorrhagy occurs at the beginning of labour, article 76. or at the conclusion of that process, articles 152. and 153.

Cases where there is more than one child, articles 143. 144. 145.

Cases where the patient had previously been affected with umbilical hernia, article 146.

Cases where convulsions happen, articles 147. 148.

Cases where the navel-string is twisted round the neck of the infant, article 149. or where it is forced down along with some part of the child, article 141.

And cases of rupture of the uterus, article 65.

EXPLANATION OF THE PLATES.

Plate CCCXLVI.

Fig. 1. A front view of the uterus in the unimpregnated state, in situ, suspended in the vagina; the anterior parts of the os ilium, with the os pubis, pudenda, perineum, and anus being removed, in order to show the internal parts.

A, The last lumbar vertebra. B, B, The os ilium. C, C, The acetabula. D, D, The inferior and posterior parts of the os ilium. E, The part covering the extremity of the coccyx. F, The inferior part of the rectum. G, G, The vagina cut open longitudinally, and stretched on each side of the cervix uteri, in order to show the manner in which the uterus is suspended in it. H, H, Part of the urinary bladder stretched on each side of the vagina and inferior part of the fundus uteri. I, The cervix uteri. K, The fundus uteri. L, L, The fallopian tubes. M, M, The ovaria. N, N, The broad ligaments. O, O, The superior part of the rectum.

Fig. 2. A view of the internal parts as seen from the right groin, the pelvis having been divided vertically.

A, The lowest vertebra of the loins. B, C, The os sacrum and coccyx with the integuments. D, The left os ilium. E, The inferior part of the os ilium. F, The os pubis of the same side. G, The foramen magnum. H, The acetabulum. I, The inferior part of the rectum. K, The os externum and vagina, the os uteri lying loosely in the latter.

L, The vesica urinaria. M, N, The cervix and fundus uteri, with a view of the cavity of the uterus. The attachment of the vagina to the uterus, and the situation of the uterus when pressed down by the intestines and bladder into the concave part of the os sacrum, are likewise shown. O, The broad ligament of the left side. P, P, The left fallopian tube. Q, The left ovarium. R, R, The superior part of the rectum and inferior part of the colon.

Fig. 3. Is a sketch taken from Dr Hunter's magnificent plate, No. 6. of the gravid uterus. All the fore part of the uterus and secundines (which included the placenta) is removed. The navel string is cut, tied, and turned to the left side over the edge of the womb. At the fundus the investing membranes are likewise turned over the edge of the womb, that they might be more apparent. The head of the child is lodged in the lower part of the womb, or in the cavity of the pelvis, and its body lies principally in the right side. Its position is diagonal or oblique, so that its posterior parts are turned forwards, and to the right side of the mother, and its fore parts are directed backwards, and to the left side. Its right foot appears between its left thigh and leg. Every part is stated by Dr Hunter to have been represented just as it was found.

Fig. 4. A front view of the gravid uterus in the first stage of labour; the anterior parts are removed, but the membranes not being ruptured, form a large bag containing the foetus and the liquor amnii.

A, A, The substance of the uterus. B, B, C, C, D, D, E, E, The bones of the pelvis. G, G, The vagina. H, H, The os uteri dilated during a pain; with I, The membranes containing the liquor amnii protruding through it. K, The chorion. L. The chorion dissected off at the back of the uterus, to allow the head of the child through the amnios.

M. The placenta; the lobulated surface, or that which is attached to the uterus, being shown.

Plate CCCXLVII.

Fig. 1. Represents a well-formed pelvis. A, A. The os ilia, properly so called. a, a. The iliac fossa. b, b. The linea innominata, making part of the brim of the pelvis. c, c. The crista of the os ilia. e, e. Their superior anterior spinous processes. B, B. The os ischium. f, f. Its tuberosities. h, h. Its branches. C, C. The body of the os pubis. i, i. The crista pubis. k, k. Its descending branch uniting with that of the ischium. l. The symphysis pubis. D, D. The os sacrum. m, m. Its base. n, n. The sacro-iliac synchondrosis. o. Its internal surface called hollow. p. Its apex to which the coccyx is joined. E. The coccyx.

Fig. 2. Represents a vertical section of the pelvis. A. The promontory of the sacrum. B. The point of the coccyx.

The distance from these two points marks the depth of the pelvis behind, which in the majority of cases is six inches.

C. The spinous process of the ischium. D. The tuberosity of the ischium. E. The crista pubis, the distance which two points marks the depth of the pelvis at the sides, and is ordinarily about four inches.

F. The foramen thyroideum.

G. The surface by which the two osa pubis are joined to form the symphysis pubis, and by which junction the depth of the pelvis at the front is reduced to about one and a half inch.

Fig. 3. Represents the brim of a well-formed pelvis. A, B. The short or conjugate diameter between pubis and sacrum, which measures commonly a little less than four inches. C, D. The long diameter in the skeleton, which, however, in the living subject, is rendered almost as short as the former, in consequence of the bellies of the psoas muscles being lodged in the lower cavity of the tunica innominata. E, F. The diagonal diameter in the skeleton, which, in fact, is the long diameter in the living body, and measures somewhat less than five inches.

Fig. 4. Represents the outlet of a well-formed pelvis. A, B. The short diameter, extending from one tuberosity of the ischium to the other, and measuring less than four inches. C, D. The long diameter, extending from the lower edge of the symphysis pubis to the point of the coccyx, and measuring nearly five inches.

Fig. 5. Represents the brim of a distorted pelvis. Fig. 6. Represents the outlet of a deformed pelvis.

Plate CCCXLVIII.

Fig. 1. The foetal heart. a. The right ventricle. b. The right auricle. c. The left auricle. d. Branches of the pulmonary veins of the right lobe of the lungs, those of the left being cut off short. e. Arteries of the left lobe of the lungs. f. The vena cava descendens. g. The aorta descendens. h. The trunk of the arteria pulmonalis. i. The ductus arteriosus.

Fig. 2. Represents the first stage of natural labour, towards its termination. A. The membranes of the ovum distending the cervix uteri, while the head of the child is just entering the brim of the pelvis. B, B. The os uteri nearly dilated. C. The vagina. D. The orificium externum.

Fig. 3. Represents the second stage of natural labour, when the head has descended into the cavity of the pelvis, while the face is still towards the sacro-iliac synchondrosis.

Fig. 4. Represents the second stage of natural labour, after the head has advanced so far that the face is in the hollow of the sacrum, and the vertex in the arch of the pubis.

Plate CCCXLIX.

Fig. 1. A view of a deformed pelvis when the deficiency of space is not very considerable.

Fig. 2. The child's skull. a. The vertex, or posterior fontanelle. b. The anterior fontanelle.

Fig. 3. and 4. The common short forceps, reduced to one-fourth of the natural size.

The instrument, when of the proper size, is in length eleven inches. The length of each handle is four inches and a half. If a straight line be drawn through the plane surface of one handle, and be produced to the extremity of the instrument (which forms the axis of the handles when both are joined), the convex edge of the blade, at the greatest distance from this line, is distant one inch; and the extreme distance of the point on the opposite edge is three-eighths of an inch. When both blades are joined their greatest width is two inches. The right-hand blade has a hinge between the handle and blade, by which it is easily introduced, while the patient lies on the left side.

Fig. 5. and 6. Views of Lowder's lever; for a particular description of which, see art. 69.

Fig. 7. Orme's perforator reduced to one-fourth the natural size.

Fig. 8. Embryotomy forceps, one-fourth the natural size.

Fig. 9. The crotchet, one-fourth the natural size.

Plate CCCL.

Fig. 1. Represents an ordinary sized child forced against the brim of a deformed pelvis.

Fig. 2. Represents the child when the feet had presented, turned into that direction by which its head is bent. best brought through the brim and cavity of the pelvis, viz. with the face towards the sacro-iliac lynchondrosis of one side.

Fig. 3. Represents the ordinary situation of the infant in breech presentations; from which it is evident, that unless the infant be very small, the natural action of the uterus cannot force it through the pelvis in this direction.

Fig. 4. Represents an arm presentation, and communicates an idea of the difficulty of bringing down the feet, and turning the infant in that position.